Every finding on record at Bright Care Home Health Provider

AMENDED The following reflects the findings of the California Department of Public Health during a complaint validation survey conducted September 30, 2024, through October 3, 2024. Census: 212 Unduplicated Admissions: 1,279 Home Visits with record reviews: 3 Record Reviews without home visits: 1 Sample Size: 4 The following Conditions of Participation were not met: G 406 484.5 Patient Rights G 940 484.105 Organizations and Administration of Services

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: The agency failed to ensure the Condition of Participation: G 406 §484.50 Patient rights was in compliance when: 1. Based on interview, and record review, the agency failed to ensure the patients received all services outlined in the plan of care for one of four sampled patients (Patient 1) when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. (Refer to G 436) 2. Based on interview, and record review, the agency failed to investigate patient and family complaints for two of four sampled patients (Patient 1 and Patient 4) when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. (Refer to G 478) b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. (Refer to G 478) 3. Based on interview, and record review, the agency failed to document both the existence of patient complaints and the resolution of patient complaints for two of four sampled patients (Patient 1 and Patient 4) when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. (Refer to G 484) b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. (Refer to G 484) 4. Based on interview, and record review, the agency failed to take action to prevent further potential violations while the complaint was being investigated for two of four sampled patients (Patient 1 and Patient 4) when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. (Refer to G 486) b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. (Refer to G 486) The cumulative effect of these systemic practices resulted in Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success. And the potential for Patients 1 and Patient 4 to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality of care and patient safety.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the patients received all services outlined in the plan of care for one of four sampled patients (Patient 1) when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. This failure caused Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the agency did not provide Patient 1 with the care and services she needed and should have. A review of the agency’s policy and procedure titled, “Patient Bill of Rights,” dated 2014, indicated, “POLICY: The Agency will provide each patient with a written notice of the patient's rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment. PURPOSE: The Agency protects and promotes the rights of each individual in its care. PROCEDURE: 1. The Agency protects and promotes the rights of each individual. In advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment, the patient is informed both verbally and in writing of all rights including: … Receive all services in the plan of care.”

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to investigate patient and family complaints for two of four sampled patients (Patient 1 and Patient 4) when: 1. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. 2. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. This failure had the potential for patients to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality of care and patient safety. 1. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. 2. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: a. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. b. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. c. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated staff receiving a complaint were supposed to discuss, verbally and in writing, the complaint with the DPCS within five (5) days of receiving the complaint. The DPCS was supposed to investigate the complaint within five (5) days after receiving the complaint. The Admin and AD/N/DPCS stated the agency staff should be aware of this process. The AD/N/DPCS stated there was no documented evidence to show the Previous/Director of Patient Care Services (P/DPCS) had received and investigated Patient 1’s complaint or Patient 4’s wife’s complaint about the late admission. The AD/N/DPCS stated she had not received Patient 4’s wife’s complaint about RN 3’s wound care or the PT’s aggressive behavior and LVN 2 and Scheduler 2 should have known to report to her. A review of the agency’s policy and procedure titled “COMPLAINT/GRIEVANCE PROCESS,” dated April 2019, indicated, “PURPOSE: To set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. POLICY: Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and [Name of agency] concerning any aspect of services, or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Patient Bill of Rights document given to each patient upon admission. PROCEDURE: 1. The organization personnel receiving the complaint will discuss, verbally and in writing, the grievance with the Clinical Supervisor within five (5) days of the alleged grievance. The Clinical Supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. 2. If the grievance cannot be resolved to the patient's satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator. The grievance must state the problem or action alleged and the date the Clinical Supervisor was notified. The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within ten (10) days of notification of failure to resolve the complaint. 3. If the patient feels his/her grievance has not been resolved after working with [Name of agency] personnel, he/she will be informed of his/her right to notify the state via the respective toll-free telephone numbers, or other methods such as ombudsman, legal services, or adult protective services. The written admission guidelines, provided to the patient upon admission, list sources of assistance for complaint resolution.”

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to document both the existence of patient complaints and the resolution of patient complaints for two of four sampled patients (Patient 1 and Patient 4) when: 1. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. 2. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. This failure had the potential for patients to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality of care and patient safety. 1. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. 2. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: a. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. b. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. c. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated complaints should be documented on a complaint form. The Admin and AD/N/DPCS stated corrective action would be specific to the complaint and the resolution would be communicated in writing to the patient. The AD/N/DPCS stated there was no documented evidence to show Patient 1’s and Patient 4’s wife’s complaints had been documented on a complaint form. The AD/N/DPCS stated there was no documented evidence to show corrective actions, specific to Patient 1’s and Patient 4’s wife’s complaints or resolutions were communicated in writing to Patient 1 or Patient 4’s wife. A review of the agency’s policy and procedure titled “COMPLAINT/GRIEVANCE PROCESS,” dated April 2019, indicated, “PURPOSE: To set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. POLICY: Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and [Name of agency] concerning any aspect of services, or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Patient Bill of Rights document given to each patient upon admission. PROCEDURE: … 4. Complaints and any action taken will be documented on a complaint form. 5. Corrective action will be specific and related to the complaint. 6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint. …”

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to take action to prevent further potential violations while the complaint was being investigated for two of four sampled patients (Patient 1 and Patient 4) when: 1. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. 2. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. This failure had the potential for patients to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality of care and patient safety. 1. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. 2. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: a. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. b. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. c. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated the agency was supposed to take action to prevent further potential violations, including retaliation, while Patient 1’s and Patient 4’s wife’s complaints was being investigated. The AD/N/DPCS stated there was no documented evidence to show the agency took action to prevent further potential violations, including retaliation, while Patient 1’s and Patient 4’s wife’s complaints were being investigated. A review of the agency’s policy and procedure titled, “Complaint Resolution,” dated March 2018, indicated, “POLICY: To provide for a prompt and equitable resolution of complaints by patients and employees. The Administrator and/or Clinical Manager will be notified of complaint. PURPOSE: To provide a mechanism for use by the patient or employee to assure response, and, if possible, resolution of a complaint in a timely manner. To provide administrative persons an opportunity to review responses to complaints as indicated. PROCEDURE: … 4. Agency will: … Take action to prevent further potential violations, including retaliation, while the complaint is being investigated…”

Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to disclose ownership and management information and did not disclose the following information to the state survey agency at the time of any change in ownership or management, in a universe of 212 patients, when: 1. The agency changed its name on February 13, 2019, and failed to notify the Department. 2. The agency hired a new Administrator (Admin) on February 1, 2023, and failed to notify the Department. 3. The agency hired a new Director of Patient Care Services (DPCS) on July 15, 2023, and failed to notify the Department. This failure had the potential to cause poor patient safety and quality of care, a lack of oversight, and not allowing the state to update its records to reflect the accurate information about the agency providing healthcare services to patients within its jurisdiction; the state was uninformed and therefore hindered in monitor compliance with regulations and taking necessary actions if issues arose. 1. A review of the agency’s “Fictitious Business Name Statement,” dated February 13, 2019, indicted, the agency’s new name. A review on the agency’s State license, dated expiration date May 3, 2025, did not indicate the agency’s new name. A review of the Department’s data base was conducted on September 30, 2024. There was no documented evidence to show a change of name application had been submitted or the Department had been notified of the name change. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he could not show documented evidence that the Department had been notified of the agency’s name change. 2. A review of the agency’s Governing Body (GB) meeting minutes, dated January 21, 2023, indicated, “AGENDA: A. Approval of New Administrator for [Name of agency]. DISCUSSION: The Governing Body needing a new Administrator starting February 1st, 2023 reviewed the qualifications of [Name of Administrator], who is currently serving as Administrator for [Name of a hospice agency]. The Governing body discussed [Name of Administrator] educational and work experience and approved him as the new administrator to take over the position from [Name of a previous Administrator] who is resigning.” A review of the Department’s data base was conducted on September 30, 2024. There was no documented evidence to show a change of Administrator application had been submitted or the Department had been notified of the change of Administrator. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he could not show documented evidence that the Department had been notified of the change of Administrator. 3. A review of the agency’s Governing Body (GB) meeting minutes, dated July 15, 2023, indicated, “AGENDA: A. Approval of Hiring a New Director of Patient Care Services. DISCUSSION: The Governing Body needing a new Director of Patient Care Services ("DPCS"), discussed the application of [Name of Previous/DPCS)]. RESOLUTION: The Governing Body hereby resolves to approve the hiring of [Name of Previous/DPCS)] as the new DPCS immediately.” A review of the Department’s data base was conducted on September 30, 2024. There was no documented evidence to show a change of DPCS application had been submitted or the Department had been notified of the change of DPCS. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he could not show documented evidence that the Department had been notified of the change of DPCS. A review of the agency’s policy and procedure titled, “Compliance with Laws and Regulations and Disclosure of Information,” dated March 2018, indicated, “POLICY: The Agency complies with all applicable laws and regulations and discloses management and ownership information. PURPOSE: To establish a mechanism for compliance with all applicable laws and regulations and to ensure that information regarding ownership and management is disclosed as required.”

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: The agency failed to ensure the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance when: 1. Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from February 1, 2023, to October 3, 2024, in a universe of 212 patients when: 1a. The agency failed to ensure the patients received all services outlined in the plan of care for Patient 1 when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. 1b. The agency failed to investigate patient and family complaints for Patient 1 and Patient 4 when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. (Refer to G 942) b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. (Refer to G 942) 1c. The agency failed to document both the existence of patient complaints and the resolution of patient complaints for Patient 1 and Patient 4 when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. (Refer to G 942) b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. (Refer to G 942) 1d. The agency failed to take action to prevent further potential violations while the complaint was being investigated for Patient 1 and Patient 4 when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. (Refer to G 942) b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. (Refer to G 942) 1e. The agency failed to disclose ownership and management information and did not disclose the following information to the state survey agency at the time of any change in ownership or management when: a. The agency changed its name on February 13, 2019, and failed to notify the Department. (Refer to G 942) b. The agency hired a new Administrator (Admin) on February 1, 2023, and failed to notify the Department. (Refer to G 942) c. The agency hired a new Director of Patient Care Services (DPCS) on July 15, 2023, and failed to notify the Department. (Refer to G 942) 1f. The Administrator (Admin) failed to be responsible for the day-to-day operations of the agency when: a. The Admin did not know the Previous Director of Patient Care Services (P/DPCS) was not available during all operating hours. (Refer to G 942) b. The Admin did not know the P/DPCS was not providing oversight of all patient care services and personnel. (Refer to G 942) c. The Admin did not know the P/DPCS was not making patient and personnel assignments. (Refer to G 942) d. The Admin did not know the P/DPCS was not coordinating patient care. (Refer to G 942) e. The Admin did not know the P/DPCS was not coordinating referrals. (Refer to G 942) f. The Admin did not know the P/DPCS was not assuring that patient needs were continually assessed. (Refer to G 942) g. The Admin did not know patient complaints were not being documented or investigated and resolutions were not provided to the patients or further violations prevented. (Refer to G 942) 1g. The Administrator (Admin) failed to ensure the Previous Director of Patient Care Services (P/DPCS) was available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1 when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. (Refer to G 942) 1h. The Administrator (Admin) failed to appoint an Administrator Designee (AD) to act in his absence. (Refer to G 942) 1i. The agency failed to ensure the Previous/Director of Patient Care Services provided oversight of all patient care services and personnel when: a. The Previous/Director of Patient Care Services (P/DPCS) was not available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1, when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. (Refer to G 942) b. The Previous/Director of Patient Care Services (P/DPCS) did not provide clinical staff with education, support or clinical direction and guidance. The P/DPCS did not review and direct patients’ changes of condition or monitor changes to patients’ care plans. (Refer to G 942) 1j. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was making patient and personnel assignments when unlicensed Scheduler 1 and Scheduler 2 chose, assigned and scheduled each clinical discipline (Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Home Health Aide (CHHA), Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST) and Medical Social Worker (MSW) to the patients without oversight and direction from the P/DPCS. (Refer to G 942) 1k. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was coordinating patient care when Registered Nurses (RN) and Licensed Vocational Nurses (LVN) were reporting patients’ changes in condition and changes to patients’ care plans to LVNs who had no RN oversight, review or direction. (Refer to G 942) 1l. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) coordinated referrals. (Refer to G 942) 1m. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was assuring that patient needs were continually assessed. (Refer to G 942) 1n. The agency failed to ensure Registered Nurses (RN) and Licensed Vocational Nurses (LVN) provided services in accordance with the Standards of Competent Performance, California Code of Regulations, Title 16 Section 1443.5 A, Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) Chapter 5, Section II: Assessment/Implementation and Business and Professions Code, Division 2, Chapter 6.5, Article 2, 2859, respectively when: a. RN 1 and RN 2 delegated the task of patient assessment for patients’ change of condition to LVNs and the LVNs independently determined and initiated a course of action. This failure had the potential for patients to suffer inadequate care and safety risks. (Refer to G 942) b. Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), LVN/CC 2, and a Licensed Vocational Nurse, After hours Triage and Case Coordinator (LVN/T/CC), received report from RNs and LVNs on patients’ change of condition, assessed the situation and independently determined and initiated a course of action without RN supervision. This failure had the potential for patients to suffer harmful situations if an LVN was not qualified to manage a specific condition or event. (Refer to G 942) 2. Based on interview and record review, the Administrator (Admin) failed to be responsible for the day-to-day operations of the agency, in a universe of 212 patients when: 2a. The Admin did not know the Previous Director of Patient Care Services (P/DPCS) was not available during all operating hours. This failure caused Patient 1 to suffer the inability to empty her urinary bladder for three days when the agency failed to send a Skilled Nurse (SN) to re-insert an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). (Refer to G 948) 2b. The Admin did not know the P/DPCS was not providing oversight of all patient care services and personnel. This failure had the potential for patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being. (Refer to G 948) 2c. The Admin did not know the P/DPCS was not making patient and personnel assignments. This failure had the potential for patients to suffer an inappropriate level of care based on their individual needs, a poor utilization of the agency's staff by assigning inappropriate healthcare professionals due to not considering patients’ specific care plans, or considering factors like geographic location, skill set, and availability. (Refer to G 948) 2d. The Admin did not know the P/DPCS was not coordinating patient care. This failure had the potential for patients to suffer unsafe, inappropriate, and ineffective care. (Refer to G 948) 2e. The Admin did not know the P/DPCS was not coordinating referrals. This failure had the potential to cause patients to suffer late admissions, delayed and inappropriate care services. (Refer to G 948) 2f. The Admin did not know the P/DPCS was not assuring that patient needs were continually assessed. This failure had the potential for patients to suffer outdated care plans that no longer aligned with the patient's changing health status, unidentified potential risks or complications, ineffective interventions, and inappropriate and unsafe care. (Refer to G 948) 2g. The Admin did not know patient complaints were not being documented or investigated and resolutions were not provided to the patients or further violations prevented. This failure had the potential for patients to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality care and patient safety. (Refer to G 948) 3. Based on interview, and record review, the Administrator (Admin) failed to ensure the Previous Director of Patient Care Services (P/DPCS) was available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for one of four sampled patients (Patient 1) when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. (Refer to G 950) 4. Based on interview, and record review the Administrator (Admin) failed to appoint an Administrator Designee (AD) to act in his absence, in a universe of 212 patients. (Refer to G 954) 5. Based on interview, and record review, the agency failed to ensure the Previous/Director of Patient Care Services provided oversight of all patient care services and personnel, in a universe of 212 patients, when: 5a. The Previous/Director of Patient Care Services (P/DPCS) was not available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1, when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. (Refer to G 958) 5b. The Previous/Director of Patient Care Services (P/DPCS) did not provide clinical staff with education, support or clinical direction and guidance. The P/DPCS did not review and direct patients’ changes of condition or monitor changes to patients’ care plans. (Refer to G 958) 6. Based on interview, and record review the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was making patient and personnel assignments, in a universe of 212 patients, when unlicensed Schedular 1 and Schedular 2 chose, assigned and scheduled each clinical discipline (Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Home Health Aide (CHHA), Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST) and Medical Social Worker (MSW) to the patients without oversight and direction from the P/DPCS. (Refer to G 960) 7. Based on interview and record review, the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was coordinating patient care, in a universe of 212 patients, when Registered Nurses (RN) and Licensed Vocational Nurses (LVN) were reporting patients’ changes in condition and changes to patients’ care plans to LVNs who had no RN oversight, review or direction. (Refer to G 962) 8. Based on interview, and record review, the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) coordinated referrals, in a universe of 212 patients. (Refer to G 964) 9. Based on interview, and record review, the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was assuring that patient needs were continually assessed, in a universe of 212 patients. (Refer to G 966) 10. Based on interview, and record review, the agency failed to ensure Registered Nurses (RN) and Licensed Vocational Nurses (LVN) provided services in accordance with the Standards of Competent Performance, California Code of Regulations, Title 16 Section 1443.5 A, Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) Chapter 5, Section II: Assessment/Implementation and Business and Professions Code, Division 2, Chapter 6.5, Article 2, 2859, respectively, in a universe of 212 patients, when: a. RN 1 and RN 2 delegated the task of patient assessment for patients’ change of condition to LVNs and the LVNs independently determined and initiated a course of action. (Refer to G 984) b. Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), LVN/CC 2, and a Licensed Vocational Nurse, After hours Triage and Case Coordinator (LVN/T/CC), received report from RNs and LVNs on patients’ change of condition, assessed the situation and independently determined and initiated a course of action without RN supervision. (Refer to G 984) The cumulative effect of these systemic practices had the potential to resulted in: Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success, Patients to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality of care and patient safety, Poor patient safety and quality of care, a lack of oversight, and not allowing the state to update its records to reflect the accurate information about the agency providing healthcare services to patients within its jurisdiction; the state was uninformed and therefore hindered in monitor compliance with regulations and taking necessary actions if issues arose, Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success, The agency to have no direction in operations resulting in the provision of inadequate and inappropriate care and services, For patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being, Patients to suffer an inappropriate level of care based on their individual needs, a poor utilization of the agency's staff by assigning inappropriate healthcare professionals due to not considering patients’ specific care plans, or considering factors like geographic location, skill set, and availability, Patients to suffer unsafe, inappropriate, and ineffective care, Patients to suffer late admissions, delayed and inappropriate care services, Patients to suffer outdated care plans that no longer aligned with the patient's changing health status, unidentified potential risks or complications, ineffective interventions, and inappropriate and unsafe care, Patients to suffer inadequate care and safety risks and harmful situations if an LVN was not qualified to manage a specific condition or event.

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 interview, and record review, the Governing Body (GB) failed to operate and manage the agency from February 1, 2023, to October 3, 2024, in a universe of 212 patients when: 1. The agency failed to ensure the patients received all services outlined in the plan of care for Patient 1 when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. 2. The agency failed to investigate patient and family complaints for Patient 1 and Patient 4 when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. 3. The agency failed to document both the existence of patient complaints and the resolution of patient complaints for Patient 1 and Patient 4 when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. 4. The agency failed to take action to prevent further potential violations while the complaint was being investigated for Patient 1 and Patient 4 when: a. Patient 1 filed a complaint about the agency not responding or sending a nurse out to re-insert a urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) and leaving her without the ability to pee for three days. b. Patient 4’s wife made three complaints to the agency: a. Patient 4’s admission was late leading to Patient 4’s wound care to be delayed for seven days. b. The admitting Registered Nurse (RN 3) refused to change the wound care order to reflect Patient 4’s inability to tolerate adhesives on his skin. c. a Physical Therapist (PT) had been very aggressive and rude and Patient 4’s wife and Patient 4 were scared the PT would hurt Patient 4. 5. The agency failed to disclose ownership and management information and did not disclose the following information to the state survey agency at the time of any change in ownership or management when: a. The agency changed its name on February 13, 2019, and failed to notify the Department. b. The agency hired a new Administrator (Admin) on February 1, 2023, and failed to notify the Department. c. The agency hired a new Director of Patient Care Services (DPCS) on July 15, 2023, and failed to notify the Department. 6. The Administrator (Admin) failed to be responsible for the day-to-day operations of the agency when: a. The Admin did not know the Previous Director of Patient Care Services (P/DPCS) was not available during all operating hours. b. The Admin did not know the P/DPCS was not providing oversight of all patient care services and personnel. c. The Admin did not know the P/DPCS was not making patient and personnel assignments. d. The Admin did not know the P/DPCS was not coordinating patient care. e. The Admin did not know the P/DPCS was not coordinating referrals. f. The Admin did not know the P/DPCS was not assuring that patient needs were continually assessed. g. The Admin did not know patient complaints were not being documented or investigated and resolutions were not provided to the patients or further violations prevented. 7. The Administrator (Admin) failed to ensure the Previous Director of Patient Care Services (P/DPCS) was available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1 when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. 8. The Administrator (Admin) failed to appoint an Administrator Designee (AD) to act in his absence. 9. The agency failed to ensure the Previous/Director of Patient Care Services provided oversight of all patient care services and personnel when: a. The Previous/Director of Patient Care Services (P/DPCS) was not available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1, when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. b. The Previous/Director of Patient Care Services (P/DPCS) did not provide clinical staff with education, support or clinical direction and guidance. The P/DPCS did not review and direct patients’ changes of condition or monitor changes to patients’ care plans. 10. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was making patient and personnel assignments when unlicensed Schedular 1 and Schedular 2 chose, assigned and scheduled each clinical discipline (Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Home Health Aide (CHHA), Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST) and Medical Social Worker (MSW) to the patients without oversight and direction from the P/DPCS. 11. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was coordinating patient care when Registered Nurses (RN) and Licensed Vocational Nurses (LVN) were reporting patients’ changes in condition and changes to patients’ care plans to LVNs who had no RN oversight, review or direction. 12. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) coordinated referrals. 13. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was assuring that patient needs were continually assessed. 14. The agency failed to ensure Registered Nurses (RN) and Licensed Vocational Nurses (LVN) provided services in accordance with the Standards of Competent Performance, California Code of Regulations, Title 16 Section 1443.5 A, Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) Chapter 5, Section II: Assessment/Implementation and Business and Professions Code, Division 2, Chapter 6.5, Article 2, 2859, respectively when: a. RN 1 and RN 2 delegated the task of patient assessment for patients’ change of condition to LVNs and the LVNs independently determined and initiated a course of action. This failure had the potential for patients to suffer inadequate care and safety risks. b. Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), LVN/CC 2, and a Licensed Vocational Nurse, After hours Triage and Case Coordinator (LVN/T/CC), received report from RNs and LVNs on patients’ change of condition, assessed the situation and independently determined and initiated a course of action without RN supervision. This failure had the potential for patients to suffer harmful situations if an LVN was not qualified to manage a specific condition or event. These failures had the potential to cause: 1. Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success. 2. 3. 4. Patients to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality of care and patient safety. 5. Poor patient safety and quality of care, a lack of oversight, and not allowing the state to update its records to reflect the accurate information about the agency providing healthcare services to patients within its jurisdiction; the state was uninformed and therefore hindered in monitor compliance with regulations and taking necessary actions if issues arose. 6. 7. Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success. 8. The agency to have no direction in operations resulting in the provision of inadequate and inappropriate care and services. 6. 9. For patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being. 6. 10. Patients to suffer an inappropriate level of care based on their individual needs, a poor utilization of the agency's staff by assigning inappropriate healthcare professionals due to not considering patients’ specific care plans, or considering factors like geographic location, skill set, and availability. 6. 11. Patients to suffer unsafe, inappropriate, and ineffective care. 6. 12. Patients to suffer late admissions, delayed and inappropriate care services. 6. 13. Patients to suffer outdated care plans that no longer aligned with the patient's changing health status, unidentified potential risks or complications, ineffective interventions, and inappropriate and unsafe care. 14. Patients to suffer inadequate care and safety risks and harmful situations if an LVN was not qualified to manage a specific condition or event. 1. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the agency did not provide Patient 1 with the care and services she needed and should have. A review of the agency’s policy and procedure titled, “Patient Bill of Rights,” dated 2014, indicated, “POLICY: The Agency will provide each patient with a written notice of the patient's rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment. PURPOSE: The Agency protects and promotes the rights of each individual in its care. PROCEDURE: 1. The Agency protects and promotes the rights of each individual. In advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment, the patient is informed both verbally and in writing of all rights including: … Receive all services in the plan of care.” 2a. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. 2b. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: i. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. ii. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. iii. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated staff receiving a complaint were supposed to discuss, verbally and in writing, the complaint with the DPCS within five (5) days of receiving the complaint. The DPCS was supposed to investigate the complaint within five (5) days after receiving the complaint. The Admin and AD/N/DPCS stated the agency staff should be aware of this process. The AD/N/DPCS stated there was no documented evidence to show the Previous/Director of Patient Care Services (P/DPCS) had received and investigated Patient 1’s complaint or Patient 4’s wife’s complaint about the late admission. The AD/N/DPCS stated she had not received Patient 4’s wife’s complaint about RN 3’s wound care or the PT’s aggressive behavior and LVN 2 and Scheduler 2 should have known to report to her. A review of the agency’s policy and procedure titled “COMPLAINT/GRIEVANCE PROCESS,” dated April 2019, indicated, “PURPOSE: To set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. POLICY: Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and [Name of agency] concerning any aspect of services, or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Patient Bill of Rights document given to each patient upon admission. PROCEDURE: 1. The organization personnel receiving the complaint will discuss, verbally and in writing, the grievance with the Clinical Supervisor within five (5) days of the alleged grievance. The Clinical Supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. 2. If the grievance cannot be resolved to the patient's satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator. The grievance must state the problem or action alleged and the date the Clinical Supervisor was notified. The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within ten (10) days of notification of failure to resolve the complaint. 3. If the patient feels his/her grievance has not been resolved after working with [Name of agency] personnel, he/she will be informed of his/her right to notify the state via the respective toll-free telephone numbers, or other methods such as ombudsman, legal services, or adult protective services. The written admission guidelines, provided to the patient upon admission, list sources of assistance for complaint resolution.” 3a. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. 3b. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: i. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. ii. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. iii. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated complaints should be documented on a complaint form. The Admin and AD/N/DPCS stated corrective action would be specific to the complaint and the resolution would be communicated in writing to the patient. The AD/N/DPCS stated there was no documented evidence to show Patient 1’s and Patient 4’s wife’s complaints had been documented on a complaint form. The AD/N/DPCS stated there was no documented evidence to show corrective actions, specific to Patient 1’s and Patient 4’s wife’s complaints or resolutions were communicated in writing to Patient 1 or Patient 4’s wife. A review of the agency’s policy and procedure titled “COMPLAINT/GRIEVANCE PROCESS,” dated April 2019, indicated, “PURPOSE: To set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. POLICY: Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and [Name of agency] concerning any aspect of services, or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Patient Bill of Rights document given to each patient upon admission. PROCEDURE: … 4. Complaints and any action taken will be documented on a complaint form. 5. Corrective action will be specific and related to the complaint. 6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint. …” 4a. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. 4b. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: i. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. ii. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. iii. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated the agency was supposed to take action to prevent further potential violations, including retaliation, while Patient 1’s and Patient 4’s wife’s complaints was being investigated. The AD/N/DPCS stated there was no documented evidence to show the agency took action to prevent further potential violations, including retaliation, while Patient 1’s and Patient 4’s wife’s complaints were being investigated. A review of the agency’s policy and procedure titled, “Complaint Resolution,” dated March 2018, indicated, “POLICY: To provide for a prompt and equitable resolution of complaints by patients and employees. The Administrator and/or Clinical Manager will be notified of complaint. PURPOSE: To provide a mechanism for use by the patient or employee to assure response, and, if possible, resolution of a complaint in a timely manner. To provide administrative persons an opportunity to review responses to complaints as indicated. PROCEDURE: … 4. Agency will: … Take action to prevent further potential violations, including retaliation, while the complaint is being investigated…” 5a. A review of the agency’s “Fictitious Business Name Statement,” dated February 13, 2019, indicted, the agency’s new name. A review on the agency’s State license, dated expiration date May 3, 2025, did not indicate the agency’s new name. A review of the Department’s data base was conducted on September 30, 2024. There was no documented evidence to show a change of name application had been submitted or the Department had been notified of the name change. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he could not show documented evidence that the Department had been notified of the agency’s name change. 5b. A review of the agency’s Governing Body (GB) meeting minutes, dated January 21, 2023, indicated, “AGENDA: A. Approval of New Administrator for [Name of agency]. DISCUSSION: The Governing Body needing a new Administrator starting February 1st, 2023 reviewed the qualifications of [Name of Administrator], who is currently serving as Administrator for [Name of a hospice agency]. The Governing body discussed [Name of Administrator] educational and work experience and approved him as the new administrator to take over the position from [Name of a previous Administrator] who is resigning.” A review of the Department’s data base was conducted on September 30, 2024. There was no documented evidence to show a change of Administrator application had been submitted or the Department had been notified of the change of Administrator. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he could not show documented evidence that the Department had been notified of the change of Administrator. 3. A review of the agency’s Governing Body (GB) meeting minutes, dated July 15, 2023, indicated, “AGENDA: A. Approval of Hiring a New Director of Patient Care Services. DISCUSSION: The Governing Body needing a new Director of Patient Care Services ("DPCS"), discussed the application of [Name of Previous/DPCS)]. RESOLUTION: The Governing Body hereby resolves to approve the hiring of [Name of Previous/DPCS)] as the new DPCS immediately.” A review of the Department’s data base was conducted on September 30, 2024. There was no documented evidence to show a change of DPCS application had been submitted or the Department had been notified of the change of DPCS. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he could not show documented evidence that the Department had been notified of the change of DPCS. A review of the agency’s policy and procedure titled, “Compliance with Laws and Regulations and Disclosure of Information,” dated March 2018, indicated, “POLICY: The Agency complies with all applicable laws and regulations and discloses management and ownership information. PURPOSE: To establish a mechanism for compliance with all applicable laws and regulations and to ensure that information regarding ownership and management is disclosed as required.” 6a. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. The Admin and HO/IM stated they were aware the P/DPCS needed to be available during all operating hours. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. The Admin stated it was his responsibility to ensure that the P/DPCS was available during all operating hours and did not. 6b. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not providing oversight of all patient care services and personnel. The Admin stated it was his responsibility to ensure the P/DPCS was providing oversight of all patient care services and personnel and had not. 6c. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she made patient and personnel assignments (the process of matching nurses, therapists and Certified Home Health Aides-CHHA- with patients for a specific period of time. This process helps to ensure that the right nurse, therapist and CHHA are assigned to the right patient, and that the needs of both the patient and the agency are met) with therapists (Physical Therapist, Occupational Therapist, Speech Therapist and Medical Social Worker) and CHHAs for the agency’s patients. Scheduler 2 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 2 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with Scheduler 1 on October 3, 2024, at 2:19 PM, Scheduler 1 stated she did not hold a nursing license. Scheduler 1 stated she made patient and personnel assignments with RNs and LVNs for the agency’s patients. Scheduler 1 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 1 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not making patient and personnel assignments. The Admin stated it was his responsibility to ensure the P/DPCS was making patient and personnel assignments and had not. 6d. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had never met, nor knew who the P/DPCS was. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not coordinating patient care. The Admin stated it was his responsibility to ensure the P/DPCS was coordinating patient care and had not. 6e. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not coordinating referrals. The Admin stated it was his responsibility to ensure the P/DPCS was coordinating referrals and had not. The Admin stated he did not know who coordinated patient referrals. 6f. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not assuring that patient needs were continually assessed. The Admin stated it was his responsibility to ensure the P/DPCS was making certain that patient needs were continually assessed and had not. 6g. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: i. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. ii. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. iii. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated they have not received report on Patient 1’s complaint or Patient 4’s wife’s complaints and should have. The Admin stated he did not know patient complaints were not being documented or investigated and resolutions were not provided to the patients or further violations prevented. The Admin stated it was his responsibility to ensure patient complaints were being documented, investigated and resolutions were provided to the patients and further violations prevented and had not. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Executive Director/Administrator,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: Responsible for planning, coordinating, managing and directing all activities and programs of the [name of agency]. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: 1. Planning and directing operations to ensure the provision of adequate and appropriate care and services. … 4. Recruiting, employing and retaining qualified personnel to maintain appropriate staffing levels. 5. Establishing and maintaining effective open channels of communication. Fosters a no-blame culture that encourages reporting of safety and quality of services issues. 6. Ensuring program personnel have current clinical information and current practices. 7. Ensuring ongoing oversight of the agency's quality management system. 8. Evaluating services and programs. 9. Ensuring personnel development including orientation, Inservice education and continuing education. … 13. Directing personnel in performance of their duties including admission, discharge and provision of service to patients. 14. Assuring appropriate personnel supervision during all operating hours. …” 7. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. The Admin and HO/IM stated they were aware the P/DPCS needed to be available during all operating hours. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. The Admin stated it was his responsibility to ensure that the P/DPCS was available during all operating hours and had not. A review of the agency’s policy and procedure titled, “APPOINTMENT OF EXECUTIVE DIRECTOR/ADMINISTRATOR,” dated April 2019, indicated, “POLICY: The Governing Body will appoint the Executive Director/Administrator through a procedure established by the Governing Body. The Executive Director/Administrator will: 1. Be responsible for the day-to-day operations of the organization. 2. Have the necessary authority to implement his/her responsibilities for the operations, as conferred by the Governing Body. … 4. Take reasonable steps to ensure that: A. The organization complies with applicable law and regulation. …” A review of the agency’s policy and procedure titled, “Supervision of Staff,” dated March 2018, indicated, “RESPONSIBILITIES: 1. The skilled nursing and other therapeutic services furnished will be under the supervision and direction of a physician or RN (who preferably has at least one year of nursing experience and is a public health nurse). 2. The Director of Clinical Services (if a supervising physician or RN) or Clinical Manager is responsible for directing patient care or services and: Is available at all times during the operating hours of the Agency. Participates in all activities relevant to the professional services furnished, including the development of qualifications and making patient and personnel assignments. Takes steps to assure: Quality of services is maintained. Staffing of the program is appropriate. Services are available. …” 8. A review of the agency’s Governing Body Meeting Minutes, dated January 6, 2023, indicated a Previous Administrator Designee (P/AD) was appointed as the Administrator Designee. A review of the agency’s Governing Body Meeting Minutes, dated January 21, 2023, indicated the Administrator (Admin) had been appointed as Admin and to start work on February 1, 2023. During an interview with the Admin on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated the P/AD’s last day of work was February 9, 2023, and he had failed to appoint a new Administrator Designee (AD). The Admin stated it had been his responsibility and the agency had been without an AD for one year and nine months. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Executive Director/Administrator,” dated April 2019, indicated, “ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: … 16. Appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the administrator.” 9a. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have been available to address Patient 1’s urinary catheter issue and if a Skilled Nurse (SN) could not be found to reinsert Patient 1’s urinary catheter the P/DPCS should have gone and inserted a new urinary catheter for Patient 1 herself. 9b. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have been available to the RNs and LVNs for education, support or clinical direction and guidance. The AD/N/DPCS stated the RNs and LVNs should not be reporting patients’ change of condition to LVNs and LVNs should not be acting independently with patient care decisions without oversight by the P/DPCS. A review of the agency’s policy and procedure titled, “Supervision of Staff,” dated March 2018, indicated, “RESPONSIBILITIES: 1. The skilled nursing and other therapeutic services furnished will be under the supervision and direction of a physician or RN (who preferably has at least one year of nursing experience and is a public health nurse). 2. The Director of Clinical Services (if a supervising physician or RN) or Clinical Manager is responsible for directing patient care or services and: Is available at all times during the operating hours of the Agency. Participates in all activities relevant to the professional services furnished, including the development of qualifications and making patient and personnel assignments. Takes steps to assure: Quality of services is maintained. Staffing of the program is appropriate. Services are available. …” A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: 1. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel. 2. Provides guidance and counseling to coordinators and Clinical Supervisors/Nursing Supervisors to assist them in continually improving all aspects of home health care services, provided through organization personnel. 3. Assists Clinical Supervisors/Nursing Supervisors in managing clinical teams and planning. 4. Provides help in assessment, planning, implementation and evaluation of patient and family/caregiver care to all clinical personnel as indicated. … 8. Assists Clinical Supervisors/Nursing Supervisors to develop skills and techniques in evaluating the performance of clinicians. … 14. Develops, implements and evaluates the orientation program for new organization personnel. Responsible for orientation of new organization personnel, either directly or by delegating to another staff member. 15. Plans and implements in service and continuing education programs to meet education and training needs of organization personnel. …” 10. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she made patient and personnel assignments with therapists (PT, OT, ST and MSW) and CHHAs for the agency’s patients. Scheduler 2 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 2 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with Scheduler 1 on October 3, 2024, at 2:19 PM, Scheduler 1 stated she did not hold a nursing license. Scheduler 1 stated she made patient and personnel assignments with RNs and LVNs for the agency’s patients. Scheduler 1 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 1 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with a Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have provided oversight and review of patient and personnel assignments to ensure patients received the appropriate level of care, based on their needs, and beneficial use of staff and did not. A review of the agency’s policy and procedure titled, “Supervision of Staff,” dated March 2018, indicated, “RESPONSIBILITIES: 1. The skilled nursing and other therapeutic services furnished will be under the supervision and direction of a physician or RN (who preferably has at least one year of nursing experience and is a public health nurse). 2. The Director of Clinical Services (if a supervising physician or RN) or Clinical Manager is responsible for directing patient care or services and: … Participates in all activities relevant to the professional services furnished, including the development of qualifications and making patient and personnel assignments.” 11. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 2 on October 1, 2024, at 2:17 PM, LVN/CC 2 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 2 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have monitored and provided guidance for the coordination of patient care. The AD/N/DPCS stated the RNs and LVNs should not be reporting patients’ change of condition to LVNs without RN oversight. LVNs should not be coordinating patient care without RN oversight and guidance. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: 1. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel. …” 12. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. During an interview with the Administrator (Admin) and an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have coordinated referrals and had not. The Admin stated he did not know who coordinated referrals for the agency. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy.” 13. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. During an interview with an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have assured that patient needs were continually assessed and had not. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy.” 14a. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would not make any determinations for a course of action but would call or text the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would not make any determinations for a course of action but would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. 14b. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated if a patient’s change in condition came across the texting application she would call the patient, assess the situation and try to resolve it. The LVN/CC 1 stated if she could not resolve the problem, she would call the physician’s office, leave a message explaining the issue and wait for a return call. LVN/CC 1 stated if the situation was severe enough, she would direct the patient to go to the Emergency Room (ER). LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs and/or changes in condition. LVN/T/CC stated if a patient’s change in condition came across the texting application she would call the patient, assess the situation and try to resolve it. The LVN/T/CC stated if she could not resolve the problem, she would call the physician’s office, leave a message explaining the issue and wait for a return call. LVN/T/CC stated if the situation was severe enough, she would direct the patient to go to the Emergency Room (ER). The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her reports on patients. A review of the agency’s policy and procedure titled, “Professional Standards of Practice,” dated 2014, indicated, “POLICY: Agency and staff will comply with accepted standards of practice and plans of care. PURPOSE: To assure appropriate care provision. PROCEDURE: 1. The Agency and staff will comply with accepted professional standards and principles that apply to the professionals who are furnishing care, e.g., state practice acts. Patient care and services will be provided for each patient according to applicable law and regulation and accepted standards of practice. Agency maintains copies of all applicable standards of practice from state licensing authority. Staff must also comply with: Federal applicable regulations. Agency policies and procedures. Accepted standards established by national organizations, boards and councils, e.g., the American Nurses' Association Standards. …” A review of the “Standards Of Competent Performance California Code of Regulations Title 16 Section 1443.5 A,” undated, indicated, “registered nurse shall be considered to be competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: delegates tasks to subordinates based on the legal scopes of practice of the subordinates and on the preparation and capability needed in the task to be delegated. 1443.5 (2) … LVN is not prepared by formal education to make RN level nursing judgments that include independent analysis, synthesis, and decision-making.” A review of the “Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) (Chapter 5, Section II: Assessment/Implementation),” undated, indicated, “Nursing assessment is defined as a collection of data. The LVN may assist in the collection of the data during the assessment process. Validation of assessment data, however, must be done by an RN. Implementation: The LVN may not independently determine or initiate a course of action.” A review of the “Business and Professions Code – BPC, Division 2. Healing Arts, Chapter 6.5 Vocational Nursing, Article 2, Scope of Regulation 2859,” undated, indicated, “(a) The practice of vocational nursing within the meaning of this chapter is the performance of services requiring those technical, manual skills acquired by means of a course in an approved school of vocational nursing, or its equivalent, practiced under the direction of a licensed physician and surgeon or registered nurse, as defined in Section 2725 …” During an interview with the Owner and the Administrator (Admin) on October 3, 2024, from 3:08 PM to 3:43 PM the Owner stated she and the Admin were the sole members of the Governing Body (GB). The Owner stated she assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Owner stated the GB had not identified that: 1. Patients had not received all services outlined in the plan of care for Patient 1 when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. 2. The agency failed to investigate patient and family complaints for Patient 1 and Patient 4. 3. The agency failed to document both the existence of patient complaints and the resolution of patient complaints for Patient 1 and Patient 4. 4. The agency failed to take action to prevent further potential violations while the complaint was being investigated for Patient 1 and Patient 4. 5. The agency failed to disclose ownership and management information for an agency name change, change in Administrator and DPCS. 6. The Administrator (Admin) failed to be responsible for the day-to-day operations of the agency when: a. The Admin did not know the Previous Director of Patient Care Services (P/DPCS) was not available during all operating hours. b. The Admin did not know the P/DPCS was not providing oversight of all patient care services and personnel. c. The Admin did not know the P/DPCS was not making patient and personnel assignments. d. The Admin did not know the P/DPCS was not coordinating patient care. e. The Admin did not know the P/DPCS was not coordinating referrals. f. The Admin did not know the P/DPCS was not assuring that patient needs were continually assessed. g. The Admin did not know patient complaints were not being documented or investigated and resolutions were not provided to the patients or further violations prevented. 7. The Administrator (Admin) failed to ensure the Previous Director of Patient Care Services (P/DPCS) was available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1 when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. 8. The Administrator (Admin) failed to appoint an Administrator Designee (AD) to act in his absence. 9. The agency failed to ensure the Previous/Director of Patient Care Services provided oversight of all patient care services and personnel when: a. The Previous/Director of Patient Care Services (P/DPCS) was not available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1, when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. b. The Previous/Director of Patient Care Services (P/DPCS) did not provide clinical staff with education, support or clinical direction and guidance. The P/DPCS did not review and direct patients’ changes of condition or monitor changes to patients’ care plans. 10. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was making patient and personnel assignments when unlicensed Schedular 1 and Schedular 2 chose, assigned and scheduled each clinical discipline (Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Home Health Aide (CHHA), Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST) and Medical Social Worker (MSW) to the patients without oversight and direction from the P/DPCS. 11. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was coordinating patient care when Registered Nurses (RN) and Licensed Vocational Nurses (LVN) were reporting patients’ changes in condition and changes to patients’ care plans to LVNs who had no RN oversight, review or direction. 12. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) coordinated referrals. 13. The agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was assuring that patient needs were continually assessed. 14. The agency failed to ensure Registered Nurses (RN) and Licensed Vocational Nurses (LVN) provided services in accordance with the Standards of Competent Performance, California Code of Regulations, Title 16 Section 1443.5 A, Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) Chapter 5, Section II: Assessment/Implementation and Business and Professions Code, Division 2, Chapter 6.5, Article 2, 2859, respectively when: a. RN 1 and RN 2 delegated the task of patient assessment for patients’ change of condition to LVNs and the LVNs independently determined and initiated a course of action. This failure had the potential for patients to suffer inadequate care and safety risks. b. Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), LVN/CC 2, and a Licensed Vocational Nurse, After hours Triage and Case Coordinator (LVN/T/CC), received report from RNs and LVNs on patients’ change of condition, assessed the situation and independently determined and initiated a course of action without RN supervision. This failure had the potential for patients to suffer harmful situations if an LVN was not qualified to manage a specific condition or event.

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 Administrator (Admin) failed to be responsible for the day-to-day operations of the agency, in a universe of 212 patients when: 1. The Admin did not know the Previous Director of Patient Care Services (P/DPCS) was not available during all operating hours. This failure caused Patient 1 to suffer the inability to empty her urinary bladder for three days when the agency failed to send a Skilled Nurse (SN) to re-insert an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). 2. The Admin did not know the P/DPCS was not providing oversight of all patient care services and personnel. This failure had the potential for patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being. 3. The Admin did not know the P/DPCS was not making patient and personnel assignments. This failure had the potential for patients to suffer an inappropriate level of care based on their individual needs, a poor utilization of the agency's staff by assigning inappropriate healthcare professionals due to not considering patients’ specific care plans, or considering factors like geographic location, skill set, and availability. 4. The Admin did not know the P/DPCS was not coordinating patient care. This failure had the potential for patients to suffer unsafe, inappropriate, and ineffective care. 5. The Admin did not know the P/DPCS was not coordinating referrals. This failure had the potential to cause patients to suffer late admissions, delayed and inappropriate care services. 6. The Admin did not know the P/DPCS was not assuring that patient needs were continually assessed. This failure had the potential for patients to suffer outdated care plans that no longer aligned with the patient's changing health status, unidentified potential risks or complications, ineffective interventions, and inappropriate and unsafe care. 7. The Admin did not know patient complaints were not being documented or investigated and resolutions were not provided to the patients or further violations prevented. This failure had the potential for patients to suffer from unidentified system wide problems within care provided, continued future occurrences, patient dissatisfaction, poor quality care and patient safety. 1. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. The Admin and HO/IM stated they were aware the P/DPCS needed to be available during all operating hours. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. The Admin stated it was his responsibility to ensure that the P/DPCS was available during all operating hours and did not. 2. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not providing oversight of all patient care services and personnel. The Admin stated it was his responsibility to ensure the P/DPCS was providing oversight of all patient care services and personnel and had not. 3. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she made patient and personnel assignments (the process of matching nurses, therapists and Certified Home Health Aides-CHHA- with patients for a specific period of time. This process helps to ensure that the right nurse, therapist and CHHA are assigned to the right patient, and that the needs of both the patient and the agency are met) with therapists (Physical Therapist, Occupational Therapist, Speech Therapist and Medical Social Worker) and CHHAs for the agency’s patients. Scheduler 2 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 2 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with Scheduler 1 on October 3, 2024, at 2:19 PM, Scheduler 1 stated she did not hold a nursing license. Scheduler 1 stated she made patient and personnel assignments with RNs and LVNs for the agency’s patients. Scheduler 1 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 1 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not making patient and personnel assignments. The Admin stated it was his responsibility to ensure the P/DPCS was making patient and personnel assignments and had not. 4. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had never met, nor knew who the P/DPCS was. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not coordinating patient care. The Admin stated it was his responsibility to ensure the P/DPCS was coordinating patient care and had not. 5. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not coordinating referrals. The Admin stated it was his responsibility to ensure the P/DPCS was coordinating referrals and had not. The Admin stated he did not know who coordinated patient referrals. 6. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated he did not know the P/DPCS was not assuring that patient needs were continually assessed. The Admin stated it was his responsibility to ensure the P/DPCS was making certain that patient needs were continually assessed and had not. 7. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she had filed a complaint with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on July 29, 2024, about the agency not responding or sending a nurse out to re-insert a urinary catheter and leaving her without the ability to pee for three days. Patient 1 stated no one reached out to her or addressed the complaint and that was why she had called the California Department of Public Health’s (CDPH) complaint hotline. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he had received Patient 1’s complaint on July 29, 2024. LVN/CC 2 stated he had not reported the complaint to the Previous/Director of Patient Care Services (P/DPCS) or the Administrator (Admin). The LVN/CC 2 stated he had not received training on how and when to report a patient complaint. A review of Patient 4’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of August 27, 2024, with a certification period of August 27, 2024 to October 25, 2024. Patient 4 had diagnoses that included critical illness myopathy (a syndrome of diseases that affect skeletal muscles causing generalized weakness in critically ill patients), pressure ulcer (a sore caused by prolonged pressure) of right buttock, unstageable (a full-thickness pressure injury where the depth of the wound is covered by slough-material that is made up of dead tissue, pus, and other debris-or eschar-a hardened, dry, black or brown dead tissue, that forms a scab-like covering over deep wounds, making it impossible to determine the extent of tissue damage) and a stage I (a red, non-blanchable area of skin that is the result of pressure) pressure ulcer of the sacral (at the bottom of the spine between the fifth segment of the spine and the tailbone) region. During Patient 4’s home visit on October 2, 2024, from 12:58 PM to 1:40 PM with a Licensed Vocational Nurse (LVN 2), Patient 4’s wife stated she had made three complaints to the agency as follows: a. Patient 4’s wife stated her husband had been discharged from the hospital on August 20, 2024, with home health services for wound care, physical therapy, and occupational therapy. Patient 4’s wife stated she called the agency on August 22, 2024, and talked to a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) and asked why her husband had not been seen and admitted by the home health agency. Patient 4’s wife stated the LVN/T/CC apologized and stated the agency had not received an order to admit Patient 4. Patient 4’s wife stated she told the LVN/T/CC that her husband had wounds that needed care and Patient 4 needed an immediate assessment and wound care or she would call the California Department of Public Health’s complaint hotline and report the agency. Patient 4’s wife stated Patient 4 was not admitted until August 27, 2024, and had gone without wound care for approximately seven days. Patient 4’s wife stated she never heard from the agency about her complaint. b. Patient 4’s wife stated a Registered Nurse (RN 3) came on August 27, 2024, to assess, admit and provide wound care for Patient 4. Patient 4’s wife stated she explained the hospital discharge wound care instructions especially that her husband’s skin could not tolerate any adhesives such as tape. Patient 4’s wife stated RN 3 stated she had to follow the physician’s order she had, and she could not change it because she was not a doctor. Patient 4’s wife stated she told RN 3 to leave the wound and she (Patient 4’s wife) would take care of it. Patient 4’s wife stated RN 3 made another visit to Patient 4 for wound care and it was the same thing, trying to place an adhesive on her husband’s skin. Patient 4’s wife stated she reported her complaint to LVN 2 and LVN 2 got the wound care order changed. Patient 4’s wife stated she never heard from the agency about her complaint. c. Patient 4’s wife stated a Physical Therapist (PT) had come to see Patient 4 and had been very aggressive and rude. Patient 4’s wife stated she a Patient 4 were scared the PT would hurt Patient 4. Patient 4’s wife stated she called the agency and spoke with a Scheduler (Scheduler 2) on October 1, 2024, and reported her complaint about the PT. Patient 4’s wife stated Scheduler 2 told her she would get a new PT for Patient 4. During an interview with the LVN/T/CC on October 3, 2024, at 2:48 PM, the LVN/T/CC stated she had no recollection of speaking with Patient 4’s wife about Patient 4’s admission. The LVN/T/CC stated Patient 4’s wife had not reported a complaint to her about the agency’s services and she had not reported a complaint to the Administrator (Admin) or Previous/Director of Patient Care Services (P/DPCS) on behalf of Patient 4’s wife. The LVN/T/CC stated she thought the agency had five to seven days to admit a patient and did not know about the 48-hour requirement. During an interview with LVN 2 on October 2, 2024, at 1:40 PM, LVN 2 stated she had received Patient 4’s wife’s complaint about RN 3’s wound care. LVN 2 stated she had gotten the wound care order changed but had not reported the complaint to the Admin or the Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS). LVN 2 stated she had not received training on reporting patient complaints. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she had seen on the agency’s texting application that Patient 4’s wife was unhappy with the Physical Therapist (PT). Scheduler 2 stated she reached out to Patient 4’s wife and told her she would switch out therapists. Scheduler 2 stated she did not report the complaint to the Admin or the AD/N/DPCS because she had not received training on reporting patient complaints. During an interview with the Admin and AD/N/DPCS on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin and AD/N/DPCS stated they have not received report on Patient 1’s complaint or Patient 4’s wife’s complaints and should have. The Admin stated he did not know patient complaints were not being documented or investigated and resolutions were not provided to the patients or further violations prevented. The Admin stated it was his responsibility to ensure patient complaints were being documented, investigated and resolutions were provided to the patients and further violations prevented and had not. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Executive Director/Administrator,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: Responsible for planning, coordinating, managing and directing all activities and programs of the [name of agency]. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: 1. Planning and directing operations to ensure the provision of adequate and appropriate care and services. … 4. Recruiting, employing and retaining qualified personnel to maintain appropriate staffing levels. 5. Establishing and maintaining effective open channels of communication. Fosters a no-blame culture that encourages reporting of safety and quality of services issues. 6. Ensuring program personnel have current clinical information and current practices. 7. Ensuring ongoing oversight of the agency's quality management system. 8. Evaluating services and programs. 9. Ensuring personnel development including orientation, In-service education and continuing education. … 13. Directing personnel in performance of their duties including admission, discharge and provision of service to patients. 14. Assuring appropriate personnel supervision during all operating hours. …”

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on interview, and record review, the Administrator (Admin) failed to ensure the Previous Director of Patient Care Services (P/DPCS) was available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for one of four sampled patients (Patient 1) when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. This failure caused Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. The Admin and HO/IM stated they were aware the P/DPCS needed to be available during all operating hours. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. The Admin stated it was his responsibility to ensure that the P/DPCS was available during all operating hours and had not. A review of the agency’s policy and procedure titled, “APPOINTMENT OF EXECUTIVE DIRECTOR/ADMINISTRATOR,” dated April 2019, indicated, “POLICY: The Governing Body will appoint the Executive Director/Administrator through a procedure established by the Governing Body. The Executive Director/Administrator will: 1. Be responsible for the day-to-day operations of the organization. 2. Have the necessary authority to implement his/her responsibilities for the operations, as conferred by the Governing Body. … 4. Take reasonable steps to ensure that: A. The organization complies with applicable law and regulation. …” A review of the agency’s policy and procedure titled, “Supervision of Staff,” dated March 2018, indicated, “RESPONSIBILITIES: 1. The skilled nursing and other therapeutic services furnished will be under the supervision and direction of a physician or RN (who preferably has at least one year of nursing experience and is a public health nurse). 2. The Director of Clinical Services (if a supervising physician or RN) or Clinical Manager is responsible for directing patient care or services and: Is available at all times during the operating hours of the Agency. Participates in all activities relevant to the professional services furnished, including the development of qualifications and making patient and personnel assignments. Takes steps to assure: Quality of services is maintained. Staffing of the program is appropriate. Services are available. …”

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview, and record review the Administrator (Admin) failed to appoint an Administrator Designee (AD) to act in his absence, in a universe of 212 patients. This failure had the potential to cause the agency to have no direction in operations resulting in the provision of inadequate and inappropriate care and services. A review of the agency’s Governing Body Meeting Minutes, dated January 6, 2023, indicated a Previous Administrator Designee (P/AD) was appointed as the Administrator Designee. A review of the agency’s Governing Body Meeting Minutes, dated January 21, 2023, indicated the Administrator (Admin) had been appointed as Admin and to start work on February 1, 2023. During an interview with the Admin on October 3, 2024, from 10:11 AM to 12:36 PM, the Admin stated the P/AD’s last day of work was February 9, 2023, and he had failed to appoint a new Administrator Designee (AD). The Admin stated it had been his responsibility and the agency had been without an AD for one year and nine months. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Executive Director/Administrator,” dated April 2019, indicated, “ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: … 16. Appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the administrator.”

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the Previous/Director of Patient Care Services provided oversight of all patient care services and personnel, in a universe of 212 patients, when: 1. The Previous/Director of Patient Care Services (P/DPCS) was not available during all operating hours (all hours which the Home Health Agency was open and providing care to patients) for Patient 1, when Patient 1’s urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine) had come out, Patient 1 was unable to empty her urinary bladder and the agency did not send a Skilled Nurse (SN) to reinsert the urinary catheter for three days. This failure caused Patient 1 to suffer lower abdominal pain, discomfort, a feeling of fullness, and urgency to urinate with no success. 2. The Previous/Director of Patient Care Services (P/DPCS) did not provide clinical staff with education, support or clinical direction and guidance. The P/DPCS did not review and direct patients’ changes of condition or monitor changes to patients’ care plans. This failure had the potential for patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being. 1. An unannounced visit was made to the facility on August 8, 2024, at 10:40 AM, to investigate a complaint regarding an allegation of not providing nursing care and services. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of July 10, 2024, with a certification period of July 10, 2024 to September 7, 2024. Patient 1 had diagnoses that included a right arm fracture (break), retention of urine (the inability to empty the urinary bladder), and presence of an indwelling urinary catheter (a thin, hollow tube inserted into the bladder through the urethra to drain urine). During an interview with Patient 1 on August 6, 2024, at 11:06 AM, Patient 1 stated she slept in a recliner at night because it was easier to breathe and she noticed, in the middle of the night on July 26, 2024, her urinary catheter had come out and was laying on the floor. Patient 1 stated the morning of July 27, 2024, she called a Licensed Vocational Nurse (LVN 1) who had been her visiting nurse and told her about the catheter coming out. Patient 1 stated LVN 1 told her she did not have any supplies with her so she could not help her. Patient 1 stated LVN 1 told her she would inform the agency about the problem but if Patient 1 did not hear anything from the agency she should go the Emergency Room (ER) and have them insert a new urinary catheter. Patient 1 stated she did not want to go back to the hospital, “Why should I go to the ER when it’s the agency’s job to care for me and my urinary catheter?!” Patient 1 stated no one from the agency contacted her on July 27, 2024. Patient 1 stated on July 28, 2024, she had been sitting on the toilet for hours trying to get her urine to come out but “it just wouldn’t!” Patient 1 stated she became so desperate she tried to reinsert the urinary catheter herself, but her right arm was in a cast so all she had was her left hand and each attempt failed. Patient 1 stated she called the agency’s after-hours line on July 28, 2024, in the afternoon, and left a message begging someone to come out and reinsert the urinary catheter, “no one called, and no one came.” Patient 1 stated on July 29, 2024, at 3:30 PM, the agency sent a Registered Nurse (RN 1), and she reinserted a new urinary catheter. Patient 1 stated by this time “I was in tears. I had suffered with the inability to pee for three days.” During an interview with a Licensed Vocational Nurse, After Hours Triage and Case Coordinator (LVN/T/CC) on August 8, 2024, at 2:42 PM, the LVN/T/CC stated she had been the triage nurse for July 27, and 28, 2024. The LVN/T/CC stated she had received a text from LVN 1 on July 27, 2024, about Patient 1’s urinary catheter coming out. LVN/T/CC stated she called Patient 1 but received no answer. LVN/T/CC stated she started calling every RN and LVN she knew to have someone go out and insert a urinary catheter for Patient 1 but she could not find anyone. The LVN/T/CC stated on July 28, 2024, at 4:23 PM, she received a phone message from Patient 1 about the urinary catheter. The LVN/T/CC stated she had not been able to reach an RN or LVN to go out and insert a urinary catheter. The LVN/T/CC stated she had tried to reach the Previous/Director of Patient Care Services (P/DPCS) all day Saturday (July 27, 2024) and Sunday (July 28, 2024) but was unable to reach her. The LVN/T/CC stated she did not know who the DPCS Designee was. The LVN/T/CC stated she did not attempt to reach the Administrator (Admin) to inform him of the problem. The LVN/T/CC stated she had given up on trying to find an RN or LVN to go and insert the urinary catheter and she could not go because she was sick. The LVN/T/CC stated she did not think there was anything more she could do so she left Patient 1 without any nursing care or services. The LVN/T/CC stated she knew the office would handle the situation on Monday (July 29, 2024). During an interview with a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) on October 1, 2024, at 1:24 PM, LVN/CC 2 stated on July 29, 2024, he came into work, scanned the texts and saw the problem with Patient 1 and her catheter. LVN/CC 2 stated he saw LVN 1's text and also saw that no one had responded to the text or Patient 1. LVN/CC 2 stated he called Patient 1 and Patient 1 was very upset because no one but him had reached out to her. LVN/CC 2 asked Patient 1 if she had gone to the ER and Patient 1 had stated, “No.” LVN/CC 2 stated he told Patient 1 he would send a nurse today to reinsert the urinary catheter and Patient 1 pleaded with him to send someone soon because she had not peed in three days. LVN/CC 2 stated he reported the incident to the LVN/T/CC, and she had not reached out to him about the incident. The LVN/CC 2 stated there was no evidence the LVN/T/CC had done anything for Patient 1. The LVN/CC 2 stated the LVN/T/CC did not tell him she tried to call nurses to go out and reinsert the urinary catheter and was unable to find any. The LVN/T/CC stated, “All she told me was she tried to call the patient, but no one answered.” The LVN/T/CC stated he did not report the incident to the Administrator (Admin) or the P/DPCS. The LVN/T/CC stated he had been instructed by the Husband of the Owner/Investment Manager (HO/IM) to report all issues and problems for patients or anything in the office to the LVN/T/CC. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have been available to address Patient 1’s urinary catheter issue and if a Skilled Nurse (SN) could not be found to reinsert Patient 1’s urinary catheter the P/DPCS should have gone and inserted a new urinary catheter for Patient 1 herself. 2. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have been available to the RNs and LVNs for education, support or clinical direction and guidance. The AD/N/DPCS stated the RNs and LVNs should not be reporting patients’ change of condition to LVNs and LVNs should not be acting independently with patient care decisions without oversight by the P/DPCS. A review of the agency’s policy and procedure titled, “Supervision of Staff,” dated March 2018, indicated, “RESPONSIBILITIES: 1. The skilled nursing and other therapeutic services furnished will be under the supervision and direction of a physician or RN (who preferably has at least one year of nursing experience and is a public health nurse). 2. The Director of Clinical Services (if a supervising physician or RN) or Clinical Manager is responsible for directing patient care or services and: Is available at all times during the operating hours of the Agency. Participates in all activities relevant to the professional services furnished, including the development of qualifications and making patient and personnel assignments. Takes steps to assure: Quality of services is maintained. Staffing of the program is appropriate. Services are available. …” A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: 1. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel. 2. Provides guidance and counseling to coordinators and Clinical Supervisors/Nursing Supervisors to assist them in continually improving all aspects of home health care services, provided through organization personnel. 3. Assists Clinical Supervisors/Nursing Supervisors in managing clinical teams and planning. 4. Provides help in assessment, planning, implementation and evaluation of patient and family/caregiver care to all clinical personnel as indicated. … 8. Assists Clinical Supervisors/Nursing Supervisors to develop skills and techniques in evaluating the performance of clinicians. … 14. Develops, implements and evaluates the orientation program for new organization personnel. Responsible for orientation of new organization personnel, either directly or by delegating to another staff member. 15. Plans and implements in service and continuing education programs to meet education and training needs of organization personnel. …”

Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This ELEMENT is not met as evidenced by: Based on interview, and record review the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was making patient and personnel assignments, in a universe of 212 patients, when unlicensed Schedular 1 and Schedular 2 chose, assigned and scheduled each clinical discipline (Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Home Health Aide (CHHA), Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST) and Medical Social Worker (MSW) to the patients without oversight and direction from the P/DPCS. This failure had the potential for patients to suffer an inappropriate level of care based on their individual needs, a poor utilization of the agency's staff by assigning inappropriate healthcare professionals due to not considering patients’ specific care plans, or considering factors like geographic location, skill set, and availability. During an interview with Scheduler 2 on October 3, 2024, at 2:04 PM, Scheduler 2 stated she did not hold a nursing license. Scheduler 2 stated she made patient and personnel assignments with therapists (PT, OT, ST and MSW) and CHHAs for the agency’s patients. Scheduler 2 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 2 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with Scheduler 1 on October 3, 2024, at 2:19 PM, Scheduler 1 stated she did not hold a nursing license. Scheduler 1 stated she made patient and personnel assignments with RNs and LVNs for the agency’s patients. Scheduler 1 stated she chose, assigned and scheduled each discipline to the patients. Scheduler 1 stated she did not know who the P/DPCS was and had never met the P/DPCS. During an interview with a Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have provided oversight and review of patient and personnel assignments to ensure patients received the appropriate level of care, based on their needs, and beneficial use of staff and did not. A review of the agency’s policy and procedure titled, “Supervision of Staff,” dated March 2018, indicated, “RESPONSIBILITIES: 1. The skilled nursing and other therapeutic services furnished will be under the supervision and direction of a physician or RN (who preferably has at least one year of nursing experience and is a public health nurse). 2. The Director of Clinical Services (if a supervising physician or RN) or Clinical Manager is responsible for directing patient care or services and: … Participates in all activities relevant to the professional services furnished, including the development of qualifications and making patient and personnel assignments.”

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was coordinating patient care, in a universe of 212 patients, when Registered Nurses (RN) and Licensed Vocational Nurses (LVN) were reporting patients’ changes in condition and changes to patients’ care plans to LVNs who had no RN oversight, review or direction. This failure had the potential for patients to suffer unsafe, inappropriate, and ineffective care. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would call the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 2 on October 1, 2024, at 2:17 PM, LVN/CC 2 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 2 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs or changes in condition. The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have monitored and provided guidance for the coordination of patient care. The AD/N/DPCS stated the RNs and LVNs should not be reporting patients’ change of condition to LVNs without RN oversight. LVNs should not be coordinating patient care without RN oversight and guidance. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: 1. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel. …”

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) coordinated referrals, in a universe of 212 patients. This failure had the potential to cause patients to suffer late admissions, delayed and inappropriate care services. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. During an interview with the Administrator (Admin) and an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have coordinated referrals and had not. The Admin stated he did not know who coordinated referrals for the agency. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy.”

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the Previous/Director of Patient Care Services (P/DPCS) was assuring that patient needs were continually assessed, in a universe of 212 patients. This failure had the potential for patients to suffer outdated care plans that no longer aligned with the patient's changing health status, unidentified potential risks or complications, ineffective interventions, and inappropriate and unsafe care. During an interview with the Previous/Director of Patient Care Services (P/DPCS) on August 8, 2024, at 3:44 PM, the P/DPCS stated she worked as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse at an acute care hospital. The P/DPCS stated she worked three days a week, 12-hour shifts and the days of the week she worked varied. The P/DPCS stated she used to be a visiting nurse at the home health agencies’ hospice division. The P/DPCS stated the Husband of the Owner/Investment Manager (HO/IM) offered her the Home Health Agencies’ DPCS position a year ago. The P/DPCS stated the HO/IM told her she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. The P/DPCS stated the HO/IM told her all she needed to do was sign paperwork sent to her house. The P/DPCS stated she tried to quit three to four months ago but the HO/IM begged her to stay. The P/DPCS stated she did not have any home health experience and never wanted the job but had felt pressured. The P/DPCS stated she could not say the name of one employee who worked at the home health agency, and she had never supervised anyone. The P/DPCS stated she did not know anything about Patient 1’s urinary catheter issue and had not been available to assist because she had been told she did not need to provide this service. The P/DPCS stated due to her fulltime ICU nursing job and caring for two little children at home she could not possibly provide any hours to the home health agency. The P/DPCS stated she had not designated a DPCS designee and had not signed a DPCS job description. The P/DPCS stated, “I didn’t want this job.” During an interview with the Administrator (Admin) and Husband of the Owner/Investment Manager (HO/IM) on September 30, 2024, at 12:32 PM, the Admin and HO/IM stated they did not recall if they had participated in the hiring of the P/DPCS. HO/IM stated he did not tell the P/DPCS she did not have to come into the office, make nursing visits, supervise staff, or provide guidance or support of any kind. HO/IM stated he did not remember having any specific conversation with the P/DPCS. The Admin stated he did not know the P/DPCS was not fulfilling her role as a DPCS. During an interview with an Administrator Designee/New/Director of Patient Care Services (AD/N/DPCS) on October 3, 2024, from 10:11 AM to 12:36 PM, the AD/N/DPCS stated the P/DPCS should have assured that patient needs were continually assessed and had not. A review of the agency’s policy and procedure titled, “Job Description: Job Title/Position: Clinical Director/Director of Patient Care Services,” dated April 2019, indicated, “JOB DESCRIPTION SUMMARY: The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy.”

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure Registered Nurses (RN) and Licensed Vocational Nurses (LVN) provided services in accordance with the Standards of Competent Performance, California Code of Regulations, Title 16 Section 1443.5 A, Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) Chapter 5, Section II: Assessment/Implementation and Business and Professions Code, Division 2, Chapter 6.5, Article 2, 2859, respectively, in a universe of 212 patients, when: 1. RN 1 and RN 2 delegated the task of patient assessment for patients’ change of condition to LVNs and the LVNs independently determined and initiated a course of action. This failure had the potential for patients to suffer inadequate care and safety risks. 2. Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), LVN/CC 2, and a Licensed Vocational Nurse, After hours Triage and Case Coordinator (LVN/T/CC), received report from RNs and LVNs on patients’ change of condition, assessed the situation and independently determined and initiated a course of action without RN supervision. This failure had the potential for patients to suffer harmful situations if an LVN was not qualified to manage a specific condition or event. 1. During an interview with a Registered Nurse (RN 1) on October 1, 2024, at 9:56 AM, RN 1 stated she had started working for the agency in February 2024. RN 1 stated she did not know who the Previous/Director of Patient Care Services (P/DPCS) was and had never met the P/DPCS. RN 1 stated she was new to home health and would have liked some guidance and support from the P/DPCS. RN 1 stated if one of her patients had a change in condition, she would not make any determinations for a course of action but would call or text the office and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and they would take care of the situation. RN 1 stated she never had an RN to report to or ask for guidance. During an interview with a Registered Nurse (RN 2) on October 2, 2024, at 10 AM, RN 2 stated she had started working for the agency in May or June of 2023. RN 2 stated she had experience as a psychiatric nurse (also known as a psychiatric mental health nurse (PMHN), a registered nurse (RN) who specializes in caring for people with mental health conditions or substance use disorders) and did not have experience with bedside nursing (a type of nursing that involves direct patient care, where nurses work face-to-face with patients to address their health needs or assessments). RN 2 stated she had been referred to the agency by a friend and received a phone call from a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) who asked her to submit paperwork. RN 2 stated she was hired without an interview and never met or knew the P/DPCS. RN 2 stated she would have appreciated support and guidance from the P/DPCS because she was so new to bedside nursing. RN 2 stated when she was lost on what to do, she would call a Licensed Vocational Nurse/Care Coordinator (LVN/CC 2) and ask what to do. RN 2 stated if one of her patients had a change in condition, she would not make any determinations for a course of action but would use the texting application and report to a Licensed Vocational Nurse/Care Coordinator (LVN/CC 1), or LVN/CC 2 and they would take care of the situation. RN 2 stated she never had an RN she could report to. 2. During an interview with a Licensed Vocational Nurse (LVN 2) on October 2, 2024, at 12:58 PM, LVN 2 stated she had started working at the agency in February 2024. LVN 2 stated she had experience working in a Skilled Nursing Facility (SNF) and had no experience in home health care. LVN 2 stated she had been hired and interviewed by a Licensed Vocational Nurse, after hours triage and case coordinator (LVN/T/CC) and had never met, nor knew who the P/DPCS was. LVN 2 stated she would have liked support from the P/DPCS while she was learning how to care for home health patients. LVN 2 stated if one of her patients had a change in condition, she would use the texting application and report to LVN/CC 1, or LVN/CC 2 and they would take care of the situation. LVN 2 stated she thought they were RNs, not LVNs. LVN 2 stated when she needed help, she would call LVN/CC 1 or LVN/CC 2 and ask for guidance. During an interview with LVN/CC 2 on October 1, 2024, at 1:24 PM, LVN/CC 2 stated he received report through the texting application from RNs and LVNs as well as the therapists (Physical Therapist, Occupational Therapist, Speech Therapists and Medical Social Worker) for the needs or change of condition of patients. LVN/CC 2 stated if a patients’ change of condition came across the text he would call the nurse to help him or her assess the situation, if the two of them were unable to resolve the situation, LVN/CC 2 stated he would call the physician's office and leave a message about the change of condition, if it was severe he would have the nurse instruct the patient to go to the Emergency Room (ER). LVN 2 stated he did not report patient change of condition to anyone else in the office. LVN/CC 2 stated he thought the P/DPCS was DPCS designee. LVN/CC 2 stated if the P/DPCS was the designee he did not know who the DPCS was. LVN/CC 2 stated he had never met or talked to the P/DPCS. LVN/CC 2 stated he did not recall ever seeing the P/DPCS in the office. LVN/CC 2 stated he never gave report to the P/DPCS and the P/DPCS never reviewed his reports and was not on the texting feed. During an interview with LVN/CC 1 on October 1, 2024, at 2:17 PM, LVN/CC 1 stated she coordinated patient care and received reports from LVNs and RNs in the field about patient care needs or changes in condition. LVN/CC 1 stated if a patient’s change in condition came across the texting application she would call the patient, assess the situation and try to resolve it. The LVN/CC 1 stated if she could not resolve the problem, she would call the physician’s office, leave a message explaining the issue and wait for a return call. LVN/CC 1 stated if the situation was severe enough, she would direct the patient to go to the Emergency Room (ER). LVN/CC 1 stated she knew who the P/DPCS was but had never met her, talked to her or gave her report on patients. During an interview with a Licensed Vocational Nurse/Triage/Care Coordinator (LVN/T/CC) on October 1, 2024, at 3:31 PM, the LVN/T/CC stated she coordinated patient care and received reports from LVNs and RNs, after hours, about patient care needs and/or changes in condition. LVN/T/CC stated if a patient’s change in condition came across the texting application she would call the patient, assess the situation and try to resolve it. The LVN/T/CC stated if she could not resolve the problem, she would call the physician’s office, leave a message explaining the issue and wait for a return call. LVN/T/CC stated if the situation was severe enough, she would direct the patient to go to the Emergency Room (ER). The LVN/T/CC stated she knew who the P/DPCS was but had never met her, talked to her or gave her reports on patients. A review of the agency’s policy and procedure titled, “Professional Standards of Practice,” dated 2014, indicated, “POLICY: Agency and staff will comply with accepted standards of practice and plans of care. PURPOSE: To assure appropriate care provision. PROCEDURE: 1. The Agency and staff will comply with accepted professional standards and principles that apply to the professionals who are furnishing care, e.g., state practice acts. Patient care and services will be provided for each patient according to applicable law and regulation and accepted standards of practice. Agency maintains copies of all applicable standards of practice from state licensing authority. Staff must also comply with: Federal applicable regulations. Agency policies and procedures. Accepted standards established by national organizations, boards and councils, e.g., the American Nurses' Association Standards. …” A review of the “Standards Of Competent Performance California Code of Regulations Title 16 Section 1443.5 A,” undated, indicated, “registered nurse shall be considered to be competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: delegates tasks to subordinates based on the legal scopes of practice of the subordinates and on the preparation and capability needed in the task to be delegated. 1443.5 (2) … LVN is not prepared by formal education to make RN level nursing judgments that include independent analysis, synthesis, and decision-making.” A review of the “Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) (Chapter 5, Section II: Assessment/Implementation),” undated, indicated, “Nursing assessment is defined as a collection of data. The LVN may assist in the collection of the data during the assessment process. Validation of assessment data, however, must be done by an RN. Implementation: The LVN may not independently determine or initiate a course of action.” A review of the “Business and Professions Code – BPC, Division 2. Healing Arts, Chapter 6.5 Vocational Nursing, Article 2, Scope of Regulation 2859,” undated, indicated, “(a) The practice of vocational nursing within the meaning of this chapter is the performance of services requiring those technical, manual skills acquired by means of a course in an approved school of vocational nursing, or its equivalent, practiced under the direction of a licensed physician and surgeon or registered nurse, as defined in Section 2725 …”