Every finding on record at Carechoices Home Health Services, LLC

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Recertification Surveys. The survey team entered the home health agency on 3/18/25 at 0830 hours. The home health agency identified the census as 183. The survey sample size was 18. GLOSSARY AND DEFINITIONS: CHHA: Certified Home Health Aide HHA: Home Health Agency HR: Human Resources LVN: Licensed Vocational Nurse P&P: Policy and Procedure RN: Registered Nurse

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the process for collaboration with the regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This failure created the potential risk of not providing the necessary care and services to the patients of the HHA during emergency events Findings: Review of the agency’s emergency preparedness program was conducted on 3/25/25, and showed the plan did not include a process for collaboration with the regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. On 3/26/25 at 1322 hours, an interview and concurrent agency document review was conducted with the Administrator. She was informed and acknowledged the finding.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P included the procedures wherein the HHA must inform State and local officials of any on-duty staff that they are unable to contact, creating the risk of unable to request for assistance during the emergency events. Findings: Review of the agency's emergency preparedness program was conducted on 3/25/25, and showed the P&P did not include the procedures wherein the HHA must inform the State and local officials of any on-duty staff that they are unable to contact. On 3/26/25 at 1322 hours, an interview and concurrent agency document review was conducted with the Administrator. She was informed and acknowledged the finding.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the communication plan included the contact information for the Federal, State, regional, and local emergency preparedness staff. This failure had the potential for not able to contact or request for assistance during the emergency events. Findings: Review of the agency's emergency preparedness program was conducted on 3/25/25. The communication plan failed to include the contact information for the Federal, State, regional, and local emergency preparedness staff. On 3/26/25 at 1322 hours, an interview and concurrent agency document review was conducted with the Administrator. She was informed and acknowledged the finding.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency communication plan included a primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies. This failure had the potential for not able to contact or request for assistance in the emergency events. Findings: Review of the agency's emergency preparedness program was conducted on 3/25/25. The communication plan failed to include the primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies. On 3/26/25 at 1322 hours, an interview and concurrent agency document review was conducted with the Administrator. She was informed and acknowledged the finding.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness training was provided to their personnel at least once every two years. This failure created the risk of not knowing what to do during the emergency situations. Findings: Review of the personnel files for RNs 2, 3, 4, and 5, LVNs 1 and 2, CHHAs 1 and 2 was conducted on 3/25/25, failed to show documented evidence the emergency preparedness training was provided once every two years. On 3/26/25 at 1330 hours, an interview and concurrent agency document review was conducted with the HR staff. The HR staff verified there were no emergency preparedness training provided to the above personnel.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure documentation of all drills and full-scale exercises were maintained. This failure had the potential for not identifying the gaps or weaknesses during the emergency exercises. Findings: Review of the agency's emergency preparedness program was conducted on 3/25/25. The Emergency Management Plan Evaluation form dated 7/8/22, showed an epidemic drill was conducted. The Emergency Management Plan Evaluation form dated 10/19/23, showed an earthquake drill was conducted. The Emergency Management Plan Evaluation form dated 7/24/24, showed a fire drill was conducted. * However, there was no documented evidence of the list/sign-in sheet of the staff who participated in the drills. On 3/26/25 at 1322 hours, an interview and concurrent agency document review was conducted with the Administrator. She was informed and acknowledged the findings. She stated the employees in the office and in the field attended the drills and full scale exercise. However, the agency was not able to provide the sign-in sheet.

The following reflects the findings of the California Department of Public Health during the concurrent Recertification and Emergency Preparedness Surveys. The survey team entered the home health agency on 3/18/25 at 0830 hours. The home health agency identified the census as 183. The survey sample size was 18. GLOSSARY AND DEFINITIONS: ADL: activities of daily living Anxiety Disorder: a serious mental disorder in which stress is out of proportion to the impact of the event and constant and overwhelming worry and fear interferes with the ability to lead a normal life BP: Blood Pressure cc: cubic centimeter(s) Cellulitis: a bacterial infection of the skin and the tissue beneath the skin CHHA: Certified Home Health Aide cm: centimeter(s) CMS: Centers for Medicare & Medicaid Services Collagen powder: wound dressing to promote healing COPD: lung disease that blocks airflow and makes breathing difficult, a condition which makes breathing difficult. According to osumc.edu, for most people, when carbon dioxide starts to build up in the body, the brain sends signals to take a breath. A person with COPD gets used to extra carbon dioxide in the blood. If a person with COPD uses too much oxygen, the carbon dioxide levels may not trigger the brain to send the signal to breathe as often or as deeply as needed. COTA: Certified Occupational Therapy Assistant Depression: a mood disorder that causes a persistent feeling of sadness and loss of interest Diastolic BP: the measurement of the pressure when the heart is at rest between heart beats DM Type II: Type 2 diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition that affects the way your body metabolizes sugar DPCS: Director of Patient Care Services ED: Emergency Department ERS button: emergency response system (medical alert system that allows individuals to summon help in an emergency with the press of a button) GACH: General Acute Care Hospital GERD: gastroesophageal reflux disease (a common condition in which the stomach contents move up into the esophagus) Glaucoma: a group of eye disorders that result in optic nerve damage, often associated with increased fluid pressure in the eye G-tube: gastrostomy tube (a tube inserted through the abdominal wall into the stomach to provide nutrition, hydration, and medications) Hepatitis B: an infection of the liver caused by the hepatitis B virus HHA: Home Health Agency Hypothyroidism: a condition in which the thyroid gland does not make enough thyroid hormone HR: Human Resource HS: at bedtime INR: international normalized ratio (test to measure of the time taken for the blood to clot) iu: international unit(s) kerlix: sterile gauze lpm: liter(s) per minute LVN: Licensed Vocational Nurse maceration: skin softening and breakdown due to prolonged exposure to moisture mcg: microgram(s) MD: Medical Doctor meq: milliequivalent mg: milligram(s) mg/dl: milligram(s) per deciliter(s) ml: milliliter(s) mm: millimeter(s) mmHg: milliliter(s) of mercury MSW: Medical Social Worker NS: normal saline OASIS: Outcome and Assessment Information Set OT: Occupational Therapy/Therapist Oxygen saturation level: the percentage of oxygen in a person's blood PCG: patient's caregiver PEG: Percutaneous Endoscopic Gastrostomy (a type of tube placed through the abdominal wall into the stomach to administer liquid nutritional formula and medications) PIP: Performance Improvement Project P&P: Policy and Procedure PO: By mouth POC: Plan of Care PRN: As Needed prophylaxis: preventive care PT: Physical Therapy/Therapist PTA: Physical Therapy Assistant Q: Every QAPI: Quality Assurance and Performance Improvement QD: Daily RN: Registered Nurse Santyl: used to remove damaged tissue from chronic skin ulcers. SBP: Systolic Blood Pressure (the pressure in the arteries when the heart beats, the top number in a blood pressure reading) SN: Skilled Nursing/Nurse SOB: shortness of breath SOC: Start of Care SR: Sustained Release TB: tuberculosis (a bacterial infection that primarily affects the lungs) Tetanus: a serious disease of the nervous system caused by a toxin-producing bacterium UTI: urinary tract infection W: Week WNL: within normal limits

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets. This failure had the potential for not reporting and coordinating the patient care assessment timely for the patients receiving care and services at the agency. Findings: Review of the OASIS Final Validation reports for September and November 2024 and January and March 2025 was initiated on 3/25/25, and showed the following: The agency’s OASIS Agency Final Validation reports from 9/2024 showed there were 157 OASIS data sets submitted more than 30 days from the assessment completion date. The agency’s OASIS Agency Final Validation reports from 11/2024 showed there were 66 OASIS data sets submitted more than 30 days from the assessment completion date. The agency’s OASIS Agency Final Validation reports from 1/2025 showed there were 113 OASIS data sets submitted more than 30 days from the assessment completion date. The agency’s OASIS Agency Final Validation reports from 3/2025 showed there were 24 OASIS data sets submitted more than 30 days from the assessment completion date. On 3/26/25 at 1413 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the written notice of the patient’s rights and responsibilities was provided to one of 18 sampled patients (Patient 16) or her authorized representative within four business days of the initial evaluation visit. This failure had the potential risk for Patient 16 or her authorized representative to not be informed of the patient’s rights and responsibilities. Findings: Review of the agency's P&P titled Admission Criteria and Process revised 11/2021 showed the patient or his/her representative will sign the required forms indicating the acceptance of services and receipt of the patient rights and privacy information. Review of Patient 16’s closed clinical record was initiated on 3/25/25. The closed clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. The patient was discharged from the agency on 10/21/25. Review of Patient 16’s admission consents for the SOC on 7/15/24, failed to show documented evidence Patient 16 or her authorized representative was provided the written notice of the patient’s rights and responsibilities within four business days of the initial evaluation visit. On 3/26/25 at 1138 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and verified the above finding. On 3/26/25 at 1557 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator provided a document of Patient 16's Admission Service Agreement dated and signed on 3/30/24, prior to Patient 16's admission date. The Administrator verified she was unable to provide documented evidence Patient 16 was provided written notice of her rights and responsibilities for the admission on 7/15/24.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed no later than five calendar days after the SOC, consistent with the patients' immediate needs for three of 17 sampled patients (Patients 7, 15, and 16). This failure created the risk of not identifying and addressing the care needs timely for these patients. 2. Review of Patient 7's clinical record was initiated on 3/19/25. The clinical record showed the SOC was 1/19/24. The patient was certified for home health services during the certification periods from 1/13/25 to 3/13/25 and 3/14/25 to 5/12/25. The OASIS-E Start of Care assessment dated 1/19/24, showed the patient information for patient’s eyes, bowel sounds, skin turgor, and skin color were not completed. In addition, the patient’s tetanus, TB, and hepatitis B immunization; and TB exposure were not completed. On 3/26/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. Review of the agency's P&P titled Initial and Comprehensive Assessment revised 11/2021 showed the assessment will be patient-specific and comprehensive to include the patients need for home care, rehabilitative care, and discharge planning needs. The assessment will also include the exact use of the current versions of the OASIS. This assessment will measure patient outcomes from the data collected at the SOC. #. Review of Patient 15’s closed clinical record was initiated on 3/21/25. The clinical record showed the SOC was 7/31/24. The patient was certified for home health services during the certification periods from 7/31/24 to 9/27/24. Review of the SOC OASIS dated 7/31/24, showed no documented evidence the eyes were assessed. In addition, cited PT visits 1-2w4 (one to two visits a week for four weeks) starting 8/5/24. However, review of Patient 15’s POC dated 7/31/24 during the certification periods from 7/31/24 to 9/27/24, showed cited PT visit for evaluation. On 3/26/25 at 1110 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding. #. Review of Patient 16’s closed clinical record was initiated on 3/25/25. The clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. Review of the SOC OASIS dated 7/15/24, showed no documented evidence the genitourinary (GU) (refers to the organs and structures involved in the reproduction and excretion) and digestive system were assessed. In addition, cited SN visits 1w4 and 3 prn for change of condition. However, review of Patient 16’s POC dated 7/15/24 during the certification periods from 7/15/24 to 9/12/24, showed cited SN visits for 1w9 and 3 prn for change of condition. On 3/26/25 at 1244 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included all of the patient's current medications to identify any potential adverse effects and drug reactions for seven of 18 sampled patients (Patients 2, 3, 4, 5, 6, 7, and 8). This failure posed the risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. #. Review of the agency’s P&P titled Medication Profile revised 11/2021 showed patient receiving medications will have a current, accurate medication profile in the clinical record. Medication profile will be updated for each change to reflect current medication and new and/or discontinued medications. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification periods from 2/1/25 to 4/1/25. The POC, for the certification periods from 2/1/25 to 4/1/25, cited SN visits 1-2w9 (one to two visits a week for nine weeks) and 2 prn beginning 2/2/25. The Medication Profile for certification periods from 2/1/25 to 4/1/25, showed the patient’s medications included the following: - Tylenol (used to relieve fever and mild to moderate pain) oral 325 mg two tablets every four hours prn - Ativan (used to treat anxiety) oral 0.5 mg one table twice daily prn - valsartan (used to treat high blood pressure) 320 mg one tablet daily - aspirin (used to relieve fever and mild to moderate pain) oral 81 mg one tablet daily -propranolol (used to treat high blood pressure or irregular heartbeat) oral 20 mg one tablet twice daily - amlodipine besylate (used to treat high blood pressure) oral 5 mg one tablet daily On 3/19/25 at 1210 hours, a joint home visit was conducted with RN 3 to Patient 4’s home in an assisted living facility. Review of the patient’s medication with RN 3 showed the patient also had an order for Imodium (anti-diarrheal drug) 2 mg one table by mouth every eight hours as needed for loose stool. In addition, Tylenol and Ativan medications were not in the patient’s medication list from her home in the assisted living facility. On 3/19/25 at 1240 hours, an interview and concurrent clinical record review was conducted with RN 3. RN 3 was informed and acknowledged the findings. #. Review of Patient 3’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/27/24. The patient was certified for home health services during the certification period from 1/26/25 to 3/26/25. The POC, for the certification period from 1/26/25 to 3/26/25, cited SN visits starting 2/5/25 once every other week, then 1w1 (one visit a week for one week), and 3 prn visits for change of condition; cited PT visits 1-2w4; and HHA visits 1w9. The Medication Profile for certification periods from 1/26/25 to 3/26/25, showed the patient’s medications included the following: - Meclizine (used to prevent and control nausea, vomiting, and dizziness caused by motion sickness) oral 25 mg one tablet every eight hours as needed - duloxetine (used to treat depression, anxiety, and chronic muscle or bone pain) oral 30 mg capsule twice daily - ergocalciferol (vitamin D supplement) oral 1.25 mg (5000 IU) one capsule on Wednesdays - lisinopril (used to treat high blood pressure) oral 20 mg one tablet daily, hold for systolic BP less than 100 mmHg - hydralazine (used to treat high blood pressure) oral 25 mg one tablet every eight hours as needed - latanoprost (used to treat glaucoma) ophthalmic 0.005% 1 ml to both eyes - gabapentin (used to treat neuropathy) oral 300 mg one capsule daily - Norco (used to treat moderate to severe pain) oral 5-325 mg one tablet every four hours as needed - tramadol (used to treat moderate to severe pain) oral 50 mg one tablet daily - milk of magnesia (used to treat constipation, upset stomach, and heartburn) oral 1200 mg/ 15 ml, give 15 ml as needed - docusate sodium (stool softener) oral 100 mg one capsule daily - Tylenol (used to relieve fever and mild to moderate pain) oral 325 mg one tablet every 4 hours as needed On 3/19/25 at 1506 hours, a joint home visit conducted with CHHA 2 to Patient 3’s home. Review of the patient’s medication with CHHA 2 and Patient 3 showed the patient did not have supply for ergocalciferol, duloxetine, meclizine, and milk of magnesia. Patient 3 was asked if she had the medication supply for the ergocalciferol, duloxetine, meclizine, and milk of magnesia. Patient 3 stated she was unsure of the supplies of her medication and medications she took were all set at the dining table. CHHA 2 was informed and acknowledged. On 3/26/25 at 1051 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 informed and acknowledged the above finding. #. Review of Patient 8’s clinical record was initiated on 3/19/25. The clinical record showed SOC was 1/16/25. The patient was certified for home health services during the certification period from 1/16/25-3/16/25. The POC, for certification period from 1/16/25-3/16/25, cited SN visits 1w1 (one visit a week for one week), 2w1, 1w4, 2 prn for change in condition and PT visits 1-2w8 starting 1/20/25. The Medication Profile for certification periods from 1/16/25-3/16/25, showed the patient’s medications included the following: - Senna (stool softener) 8.6 mg one tablet daily as needed - levothyroxine sodium oral (used to treat hypothyroidism) oral 125 mcg one tablet daily - metformin (used to treat type 2 diabetes) oral 50 mg one tablet twice daily - Miralax (used to treat constipation) oral 17 gram one packet as directed as needed - rosuvastatin (used to treat high cholesterol) oral 20 mg one tablet daily - tramadol (used to treat moderate to severe pain) oral 50 mg every eight hours as needed - TUMS (used to relieve heartburn, indigestion, and upset stomach) oral 500 mg one to two tablet daily as needed - liothyronine sodium (used to treat severe hypothyroidism) oral 5 mcg one tablet daily - Tylenol Extra Strength (used to relieve fever and mild to moderate pain) oral 500 mg one to two tablets daily every six hours as needed - losartan potassium-hydrochlorothiazide (used to treat high blood pressure) oral 50-12.5 mg one tablet daily - famotidine (used to treat ulcers and GERD) oral 20 mg one tablet twice daily On 3/20/25 at 1000 hours, a joint home visit was conducted with PT 2 to Patient 8’s home. Review of the patient’s medication with Patient 8 and PT 2 showed the patient was also taking deferasirox (used to treat iron toxicity) oral 360 mg one tablet daily, pantoprazole (used to treat ulcers and GERD) oral 40 mg daily at bedtime, and ibandronate 150 mg oral every 30 days. Patient 8 stated she was not taking the Senna, Miralax, TUMS, and famotidine. PT 2 was informed and acknowledged. On 3/26/25 hours at 1054 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding. #. Review of Patient 6's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 9/7/22. The patient was certified for home health services during the certification periods from 12/25/24 to 2/22/25 and 2/23/25 to 4/23/25. The Medication Profile for the certification period from 12/25/24 to 2/22/25, showed the patient's medications included Probiotic (supplement) 50 billion CFU take PO QD, Imodium A-D (for diarrhea) 2 mg 1-2 tablets PO every diarrhea, hold once formed stool, Acyclovir external (dermatological) 5% using gloved finger apply to affected area/blisters enough to cover all the sores 5x a day until healed, acetaminophen oral (analgesic) 325 mg 1 to 2 tablets PO Q4 to 6H PRN for mild to moderate pain, Loratadine oral (antihistamines) 10 mg one tablet PO QD PRN for allergies, Flonase Nasal (nasal agents) 50 mcg/act 2 ml, inhale into each nostril every morning PRN for congestion, Vitamin D3 oral (supplement) 50 mcg one capsule PO QD, Urinary X (genitourinary agents) take two tablets PO QD, Gas-X Extra Strength (gastrointestinal agents) 125 mg one capsule PO PRN, pantoprazole sodium oral (ulcer drugs) 40 mg one tablet PO QD, albuterol sulfate inhalation (bronchodilator) 108 mcg/act 2 puffs inhale into lungs every 4 to 6 hours PRN for SOB and Breo Elipta inhalation (bronchodilators) 100-25 mcg/inh one puff inhale into lungs QD rinse mouth after use and spit. A joint home visit with LVN 1 was conducted on 3/19/25 at 0915 hours to Patient 6's home. Review of the medications with the patient was performed. The medications included the following: -Imodium A-D 2 mg 1-2 tablets PO every diarrhea. However, the instructions on the medication bottle showed 2 capsule PO Q6H PRN for diarrhea. -Acyclovir external 5% using gloved finger apply to affected area/blisters enough to cover all the sores 5x a day until healed. However, the instructions on the bottle showed to apply to affected area 3x a day. -Urinary X (genitourinary agents) take 2 tablets PO QD. However, the patient was taking one to three tablets daily instead of 2 tablets daily as written on the medication profile and -Gas-X Extra Strength125 mg one capsule PO PRN, However, the patient was taking two tablets QHS instead of one capsule as PRN as written on the medication profile. On 3/19/25 at 1044 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. On 3/26/25 at 1526 hours, the finding was shared with the Clinical Manager. The Clinical Manager acknowledged the findings. #. Review of Patient 5's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 12/18/23. The patient was certified for home health services during the certification period from 12/12/24 to 2/2/25 and 2/10/25 to 4/10/25. The Medication Profile for the certification period from 2/10/25 to 4/10/25, showed the patients medication included Wellbutrin SR (antidepressants) 150 mg one tablet by mouth in the morning, Lipitor Oral (anti-hyperlipidemic) 20 mg one tablet by mouth every evening, carbidopa- levodopa ER(anti-Parkinson) 50-100 mg one tablet take by mouth twice daily, Depakote oral (anti-convulsant) 500 mg one tablet take by mouth once every morning, Vitamin D3 oral (supplement) 125 mcg (5000 IU) one capsule take by mouth every morning, Cyanocobalamin oral (hematopoietic agent) 1000 mcg one tablet take one tablet by mouth every morning, aspirin oral (analgesics) 81 one tablet take by mouth once every morning, Tylenol oral (analgesics) 325 mg two tablets PO Q4H PRN and Zoloft oral (antidepressants) 50 mg one tablet PO daily. A joint home visit with COTA 1 was conducted on 3/19/25 at 1345 hours, to Patient 5's home. Review of the patient's medications with the family member showed the patient was on anastrozole (hormone receptor) 1 mg tablet one tablet PO QD, Benadryl (antihistamine) 25 mg one tablet at night, Kisqali (kinase inhibitor) 400 mg take two tablets at night and Senokot (stool softener) 17.2 mg take one tablet in the morning and one tablet in the afternoon. However, these medications were not listed on the medication profile. In addition, the cyanocobalamin oral was not available at bedside. The PCG was asked if the patient was taking cyanocobalamin. The PCG replied, the patient was not on this medication. However, the cyanocobalamin was listed on the patient current medication list. On 3/19/25 at 1442 hours, an interview and concurrent clinical record review was conducted with the COTA 1. The COTA 1 was informed and acknowledged the findings. On 3/30/25 at 1333 hours, the findings were shared with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. #. Review of the agency’s P&P titled Medication Management revised 11/2021 showed patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. #. Review of Patient 2's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 7/10/24. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/5/25. The POC for the certification period from 3/7/25 to 5/5/25 showed SN visits 1w1 (one visit for the first week), 3w8 (three visits for eight weeks). The Medication Profile showed the patient’s medication included the following: -Spironolactone (used to treat high blood pressure) 25 mg one-half tablet daily; -Losartan potassium (used to treat high blood pressure) 50 mg one tablet by mouth daily; -Toprol XL (used to treat high blood pressure) 25 mg one tablet by mouth daily; -Lantus (help to control bood sugar levels) 20 ml. Inject under the skin every morning; -Aspirin (help prevent heart attack or stroke) 81 mg one tablet by mouth daily; -Alprazolam (needed for sleep) 0.25 mg take one tablet by mouth at bedtime; -Tylenol (for pain) 325 mg take two tablets by mouth every six hours if needed; -Potassium Chloride (mineral supplement to prevent low amounts of potassium in the blood) 20 meq one tablet by mouth daily; -Ezetimibe (cholesterol lowering medications) ten mg one tablet daily; -Atorvastatin (reduces the amount of cholesterol in the blood) 40 mg one tablet at bedtime; -Apixaban (helps preventing harmful clots from forming in the blood vessels) five mg one tablet two times a day; -Gabapentin (for nerve pain) 600 mg two tablets at bedtime. On 3/19/25 at 1100 hours, a joint visit was conducted with RN 2 to Patient 2’s home. Review of the patient’s medications with RN 2, the patient stated losartan was discontinued a month ago. Patient was not taking toprol XL, potassium chloride, ezetimibe and atorvastatin anymore. Patient started to take iron and vitamin D3 one tablet a day two weeks ago. Furthermore, patient was injecting 20 units of lantus for blood sugar level of 150 and 15 units of lantus for blood sugar level of 125. These changes in medications were not reflected in the patient’s medication profile. Furthermore, no copy of the medication list/profile was available at the patient’s home. The RN 2 acknowledged the above findings. Review of Patient 7's clinical record was initiated on 3/19/25. The clinical record showed the SOC was 1/19/24. The patient was certified for home health services during the certification periods from 1/13/25 to 3/13/25 and 3/14/25 to 5/12/25. Review of the medication profile for the certification period from 3/14/25 to 5/12/25, showed the patient’s medication included zinc (supplement) 50 mg PO one tablet daily, acetaminophen (analgesic) 500 mg one capsule PO Q six hours PRN for moderate pain, acetaminophen 500 mg two tablets PO Q eight hours PRN for pain, ferrous gluconate (supplement) 324 mg 38 iron one tablet daily, Zofran (antiemetic) 4 mg one tablet Q six hours PRN for nausea/vomiting, Vitamin B Complex (supplement) one tablet PO daily, multivitamin (supplement) one tablet daily, tramadol (opioid analgesic) 50 mg one tablet Q six hours PRN for pain A joint home visit with LVN 2 was conducted on 3/19/25 at 1400 hours, to Patient 7's home. Review of the patient’s medications with the patient and LVN 2 showed the following information: -The patient’s supply of zinc had an expiration date of 11/24; acetaminophen had an expiration date of 4/23; and Zofran had a discard date of 3/30/24 -The patient stated she is taking ferrous sulfate 325 mg iron 65 mg which started a couple of months ago instead of ferrous gluconate 324 mg 38 iron one tablet daily. -The patient’s supply of Vitamin B complex had an expiration date of 9/24. The patient stated she do not take this medication often and only takes it if she can’t wake up/groggy. -The patient’s supply of multivitamin is now in liquid form. The patient stated she took the multivitamin liquid form 3 months ago and took one tablespoon daily -The patient stated she do not take tramadol because it is habit forming. * However, the SN failed to update the medication profile. In addition, the SN failed to ensure the medications were not expired. On 3/26/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. Findings: Review of the agency’s P&P titled Medication Profile revised 11/2021 showed patient who are receiving medications will have a current, accurate medication profile in the clinical record. Medication profile will be updated for each change to reflect current medication and new and/or discontinued medications. 1. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification period from 2/1/25 to 4/1/25. The POC, for the certification periods from 2/1/25 to 4/1/25, cited SN visits 1-2W9 (one to two visits a week for nine weeks) and 2 PRN visits beginning 2/2/25. The Medication Profile for the certification period from 2/1/25 to 4/1/25, showed the patient’s medications included the following: - Tylenol (analgesic) 325 mg two tablets orally every four hours PRN (no indication) - Ativan (antianxiety) 0.5 mg one tablet orally twice daily PRN anxiety - valsartan (antihypertensive) 320 mg one tablet orally daily - aspirin (antiplatelet) 81 mg one tablet orally daily -propranolol (beta blocker) 20 mg one tablet orally twice daily - amlodipine besylate (antihypertensive) 5 mg one tablet orally daily On 3/19/25 at 1210 hours, a joint home visit was conducted with RN 3 to the assisted living facility where Patient 4 resided. Review of the patient’s medication with RN 3 showed the patient was taking Imodium (anti-diarrheal drug) 2 mg one tablet by mouth every eight hours as needed for loose stool. In addition, Patient 4 was not taking Tylenol and Ativan medications at the assisted living facility. On 3/19/25 at 1240 hours, an interview and concurrent clinical record review was conducted with RN 3. RN 3 was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/27/24. The patient was certified for home health services during the certification period from 1/26/25 to 3/26/25. The POC, for the certification period from 1/26/25 to 3/26/25, cited SN visits starting 2/5/25 once every other week, then 1w1 (one visit a week for one week), and 3 PRN visits for change of condition; PT visits 1-2w4; and HHA visits 1w9. The Medication Profile for certification period from 1/26/25 to 3/26/25, showed the patient’s medications included the following: - meclizine (antihistamine) 25 mg one tablet orally every eight hours PRN (no indication) - duloxetine (antidepressant) 30 mg capsule orally twice daily - ergocalciferol (supplement) 1.25 mg (5000 iu) one capsule orally on Wednesdays - lisinopril (antihypertensive) 20 mg one tablet orally daily, hold for SBP less than 100 mmHg - hydralazine (antihypertensive) 25 mg one tablet orally every eight hours PRN (no indication) - latanoprost (antiglaucoma) ophthalmic 0.005% 1 ml drop to both eyes - gabapentin (anticonvulsant) 300 mg orally one capsule daily - Norco (opioid analgesic) 5-325 mg one tablet orally every four hours PRN (no indication) - tramadol (opioid analgesic) 50 mg one tablet orally daily - milk of magnesia (laxative) 1200 mg/15 ml orally, give 15 ml PRN (no indication) - docusate sodium (stool softener) 100 mg one capsule orally daily - Tylenol (analgesic) oral 325 mg one tablet every 4 hours PRN (no indication) On 3/19/25 at 1506 hours, a joint home visit conducted with CHHA 2 to Patient 3’s home. Review of the patient’s medication with CHHA 2 and Patient 3 showed the patient did not have ergocalciferol, duloxetine, meclizine, and milk of magnesia medications. When asked, Patient 3 stated she was unsure of her medication and took whatever medications were set at the dining table. CHHA 2 was informed and acknowledged finding. On 3/26/25 at 1051 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 informed and acknowledged the above finding. 3. Review of Patient 8’s clinical record was initiated on 3/19/25. The clinical record showed SOC was 1/16/25. The patient was certified for home health services during the certification period from 1/16/25 to 3/16/25. The POC, for certification period from 1/16/25 to 3/16/25, cited SN visits 1w1, 2w1, 1w4, and 2 PRN visits for change in condition; and PT visits 1-2w8 starting 1/20/25. The Medication Profile for certification period from 1/16/25 to 3/16/25, showed the patient’s medications included the following: - Senna (stool softener) 8.6 mg one tablet orally daily PRN (no indication) - levothyroxine sodium oral (used to treat hypothyroidism) 125 mcg one tablet orally daily - metformin (antidiabetic) 50 mg one tablet orally twice daily - Miralax (laxative) 17 grams one packet as directed orally PRN (no indication) - rosuvastatin (antilipemic) 20 mg orally one tablet daily - tramadol (opioid analgesic) 50 mg every eight hours PRN for pain - TUMS (antacid) 500 mg one to two tablets daily PRN (no indication) - liothyronine sodium (thyroid agent) 5 mcg one tablet orally daily - Tylenol Extra Strength (analgesic) 500 mg one to two tablets orally daily every six hours PRN (no indication) - losartan potassium-hydrochlorothiazide (antihypertensive) 50-12.5 mg one tablet orally daily - famotidine (anti-GERD) 20 mg one tablet orally twice daily On 3/20/25 at 1000 hours, a joint home visit was conducted with PT 2 to Patient 8’s home. Review of the patient’s medication with Patient 8 and PT 2 showed the patient was also taking deferasirox (used to treat iron toxicity) 360 mg one tablet orally daily, pantoprazole (anti-GERD) 40 mg orally daily at bedtime, and ibandronate (biphosphonate)150 mg orally every 30 days. Patient 8 stated she was not taking the Senna, Miralax, TUMS, and famotidine. PT 2 was informed and acknowledged the findings. On 3/26/25 hours at 1054 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings. 4. Review of Patient 7's clinical record was initiated on 3/19/25. The clinical record showed the SOC was 1/19/24. The patient was certified for home health services during the certification periods from 1/13/25 to 3/13/25 and 3/14/25 to 5/12/25. Review of the medication profile for the certification period from 3/14/25 to 5/12/25, showed the patient’s medication included zinc (supplement) 50 mg one tablet PO daily, acetaminophen (analgesic) 500 mg one capsule PO Q six hours PRN for moderate pain, acetaminophen 500 mg two tablets PO Q eight hours PRN for pain, ferrous gluconate (supplement) 324 mg 38 iron one tablet PO daily, Zofran (antiemetic) 4 mg one tablet PO Q six hours PRN for nausea/vomiting, vitamin B Complex (supplement) one tablet PO daily, multivitamin (supplement) one tablet PO daily, tramadol (opioid analgesic) 50 mg one tablet Q six hours PRN for pain A joint home visit with LVN 2 was conducted on 3/19/25 at 1400 hours, to Patient 7's home. Review of the patient’s medications with the patient and LVN 2 showed the following information: -The patient’s zinc medication had an expiration date of 11/24; acetaminophen had an expiration date of 4/23; and Zofran had a discard date of 3/30/24 -The patient stated she was taking ferrous sulfate 325 mg iron 65 mg which started a couple of months ago instead of ferrous gluconate 324 mg 38 iron one tablet daily. -The patient’s Vitamin B complex had an expiration date of 9/24. The patient stated she did not take this medication often and would only take it if she could not wake up/groggy. -The patient’s supply of multivitamin was now in liquid form. The patient stated she took the multivitamin liquid form three months ago and took one tablespoon daily -The patient stated she did not take tramadol because it is habit forming. * However, the SN failed to update the medication profile. In addition, the SN failed to ensure the medications were not expired. On 3/26/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 5. Review of Patient 6's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 9/7/22. The patient was certified for home health services during the certification periods from 12/25/24 to 2/22/25 and 2/23/25 to 4/23/25. The Medication Profile for the certification period from 12/25/24 to 2/22/25, showed the patient's medications included Probiotic (supplement) 50 billion CFU PO QD, Imodium A-D (for diarrhea) 2 mg 1-2 tablets PO every diarrhea, hold once formed stool, Acyclovir external (dermatological) 5% using gloved finger apply to affected area/blisters enough to cover all the sores five times a day until healed, acetaminophen oral (analgesic) 325 mg one to two tablets PO Q4 to 6H PRN for mild to moderate pain, Loratadine oral (antihistamine) 10 mg one tablet PO QD PRN for allergies, Flonase Nasal (nasal agents) 50 mcg/act 2 ml, inhale into each nostril every morning PRN for congestion, Vitamin D3 oral (supplement) 50 mcg one capsule PO QD, Urinary X (genitourinary agents) take two tablets PO QD, Gas-X Extra Strength (gastrointestinal agents) 125 mg one capsule PO PRN (no indication), pantoprazole sodium oral (ulcer drugs) 40 mg one tablet PO QD, albuterol sulfate inhalation (bronchodilator) 108 mcg/act 2 puffs inhale into lungs every 4 to 6 hours PRN for SOB and Breo Elipta inhalation (bronchodilators) 100-25 mcg/inh one puff inhale into lungs QD rinse mouth after use and spit. A joint home visit with LVN 1 was conducted on 3/19/25 at 0915 hours to Patient 6's home. Review of the medications with the patient was performed. The medications included the following: -Imodium A-D 2 mg 1-2 tablets PO every diarrhea. However, the instructions on the medication bottle showed 2 capsules PO Q6H PRN for diarrhea. -Acyclovir external 5% using gloved finger apply to affected area/blisters enough to cover all the sores 5x a day until healed. However, the instructions on the bottle showed to apply to affected area three times a day. -Urinary X (genitourinary agents) take 2 tablets PO QD. However, the patient was taking one to three tablets daily instead of 2 tablets daily as written on the medication profile and -Gas-X Extra Strength125 mg one capsule PO PRN, However, the patient was taking two tablets QHS instead of one capsule as PRN as written on the medication profile. On 3/19/25 at 1044 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. On 3/26/25 at 1526 hours, the finding was shared with the Clinical Manager. The Clinical Manager acknowledged the findings. 6. Review of Patient 5's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 12/18/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/2/25 and 2/10/25 to 4/10/25. The Medication Profile for the certification period from 2/10/25 to 4/10/25, showed the patients medication included Wellbutrin SR (antidepressants) 150 mg one tablet by mouth in the morning, Lipitor (antilipemic) 20 mg one tablet by mouth every evening, carbidopa- levodopa ER (anti-Parkinson) 50-100 mg one tablet by mouth twice daily, Depakote oral (anticonvulsant) 500 mg one tablet by mouth once every morning, vitamin D3 oral (supplement) 125 mcg (5000 IU) one capsule by mouth every morning, cyanocobalamin oral (hematopoietic agent) 1000 mcg one tablet by mouth every morning, aspirin oral (analgesics) 81 one tablet take by mouth once every morning, Tylenol (analgesics) 325 mg two tablets PO Q4H PRN (no indication) and Zoloft (antidepressant) 50 mg one tablet PO daily. A joint home visit with COTA 1 was conducted on 3/19/25 at 1345 hours, to Patient 5's home. Review of the patient's medications with the family member showed the patient was on anastrozole (hormone receptor) 1 mg tablet one tablet PO QD, Benadryl (antihistamine) 25 mg one tablet at night, Kisqali (kinase inhibitor) 400 mg two tablets at night and Senokot (stool softener) 17.2 mg take one tablet in the morning and one tablet in the afternoon. However, these medications were not listed on the medication profile. In addition, the cyanocobalamin oral was not available at bedside. The PCG was asked if the patient was taking cyanocobalamin. The PCG replied, the patient was not on this medication. However, the cyanocobalamin was listed on the patient's current medication list. On 3/19/25 at 1442 hours, an interview and concurrent clinical record review was conducted with COTA 1. The COTA 1 was informed and acknowledged the findings. On 3/30/25 at 1333 hours, the findings were shared with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. 7. Review of Patient 2's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 7/10/24. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/5/25. The POC for the certification period from 3/7/25 to 5/5/25 showed SN visits 1w1 (one visit for the first week), 3w8 (three visits for eight weeks). The Medication Profile showed the patient’s medication included the following: -spironolactone (antihypertensive) 25 mg one-half tablet by mouth daily -losartan potassium (antihypertensive) 50 mg one tablet by mouth daily -Toprol XL (antihypertensive) 25 mg one tablet by mouth daily -Lantus (antidiabetic) 20 ml. Inject under the skin every morning -aspirin (antiplatelet) 81 mg one tablet by mouth daily -alprazolam (benzodiazepine) 0.25 mg take one tablet by mouth at bedtime -Tylenol (analgesic) 325 mg take two tablets by mouth every six hours PRN (no indication) -potassium chloride (supplement) 20 meq one tablet by mouth daily -ezetimibe (antilipemic) 10 mg one tablet by mouth daily -atorvastatin (antilipemic) 40 mg one tablet by mouth at bedtime -apixaban (anticoagulant) 5 mg one tablet by mouth two times a day -gabapentin (anticonvulsant) 600 mg two tablets by mouth at bedtime. On 3/19/25 at 1100 hours, a joint visit was conducted with RN 2 to Patient 2’s home. Review of the patient’s medications with RN 2, showed losartan was discontinued a month ago; and the patient was not taking Toprol XL, potassium chloride, ezetimibe and atorvastatin. In addition, Patient 2 started to take iron and vitamin D3 one tablet a day two weeks ago. Furthermore, patient was injecting 20 units of Lantus for blood sugar level of 150 mg/dl and 15 units for blood sugar level of 125 mg/dl. However, these changes in medications were not reflected in the patient’s medication profile and there was no copy of the medication list/profile was available at the patient’s home. RN 2 was informed and acknowledged the above findings.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for five of 18 sampled patients (Patients 2, 6, 9, 16, and 17). This failure had the potential for not addressing the care needs for these patients. #. Review of Patient 16’s closed clinical record was initiated on 3/25/25. The clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. Review of the OASIS Recertification dated 9/10/25, showed the RN had performed a comprehensive assessment. However, the sections for height and weight in the comprehensive assessment were left blank. On 3/26/25 at 1307 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. #. Review of Patient 6's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 9/7/22. The patient was certified for home health services during the certification periods from 12/25/24 to 2/22/25 and 2/23/25 to 4/23/25. Review of the OASIS E- Recertification dated 2/18/25, showed the RN had performed a comprehensive assessment. However, the sections for height and weight in the comprehensive assessment were left blank. On 3/26/25 at 1526 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 17's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification periods from 9/28/24 to 11/26/24. Review of the OASIS E- Recertification dated 9/25/24, showed the RN had performed a comprehensive assessment. However, the sections for height and weight in the comprehensive assessment were left blank. In addition, review of the OASIS E- Discharge dated 11/25/24, showed the RN had performed a comprehensive assessment. However, the sections for height and weight in the comprehensive assessment were left blank. On 3/26/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager reviewed the clinical record and acknowledged the findings. #. Review of Patient 2's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 7/10/24. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/5/25. Review of the OASIS Recertification dated 3/6/25, showed the RN had performed a comprehensive assessment. * However, the sections for height and weight in the comprehensive assessment were left blank. On 3/27/25 at 1410 hours, an interview and concurrent clinical record review was conducted with the RN 1. The RN 1 was informed and acknowledged the finding. #. Review of Patient 9's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 8/3/24. The patient was certified for home health services during the certification periods from 1/30/25 to 3/30/25. The OASIS-E Recertification assessment dated 1/27/25, showed the patient’s tetanus, TB, and hepatitis B immunization; and TB exposure were not completed. On 3/26/25 at 1300 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge assessment was completed for two of 18 sampled patients (Patients 16 and 17). This failure had the potential for not addressing the care needs for these patients. Findings: 1. Review of Patient 16’s closed clinical record was initiated on 3/25/25. The closed clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. The patient was discharged from the agency on 10/21/25. Review of the Communications dated 10/22/25, showed Patient 16 was discharged from the agency to a hospice. Review of the Discharge OASIS dated 10/21/25, showed the RN had completed the discharge assessment. However, the sections for the height, weight, bowel sounds, and physician’s information were left blank. In addition, the section for current condition of the patient at discharge was coded “0”. However, there was no legend to show the definition of “0.” On 3/26/25 at 1332 hours, an interview and concurrent closed clinical record review was conducted with RN 1. When asked, RN 1 stated she did not know what “0” meant and the nurse should have documented in a narrative form. RN 1 was informed and acknowledged the above finding. 2. Review of Patient 17's closed clinical record was initiated on 3/21/25. The closed clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification period from 9/28/24 to 11/26/24. The patient was discharged from the agency on 11/25/24. Review of the OASIS E- Discharge dated 11/25/24, showed the RN had performed a comprehensive assessment. However, the sections for height and weight in the comprehensive assessment were left blank. On 3/26/25 at 1008 hours, an interview and concurrent closed clinical record review was conducted with the Clinical Manager. The Clinical Manager reviewed the clinical record and acknowledged the findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the care was provided as per the POC and P&P for three of 18 sampled patients (Patients 5, 7, and 11). This failure had the potential for not addressing the care needs for these patients. #. Review of Patient 11's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 1/10/25. The patient was certified for home health services during the certification periods from 1/10/25 to 3/10/25. The POC for the certification period from 1/10/25 to 3/10/25 cited SN visits 1W1 (one visit for one week), 2W2 (two times for two weeks), 1-2W6 (one to two times a week for six weeks) plus 2 as needed. Review of the SN visit note showed a missed visits on Week 3 dated 1/23/25. *However, review of the clinical record failed to show documented evidenced of an attempt to re-schedule the visit for the week as per P&P. On 3/26/25 at 1410 hours, an interview and concurrent clinical record review was conducted with the RN 1. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 7's clinical record was initiated on 3/19/25. The clinical record showed the SOC was 1/19/24. The patient was certified for home health services during the certification periods from 1/13/25 to 3/13/25 and 3/14/25 to 5/12/25. The POC, during the certification period from 1/13/25 to 3/13/25, cited SN visits 1W9 plus two PRN visits for change in condition beginning week of 1/12/25. The SN notes showed the patient did not have a visit during the week of 3/2/25 to 3/8/25. The Missed Visit Form dated 3/5/25, showed there was no answer to the phone call. Documentation showed the SN called the patient several times, there was no answer, and was unable to leave a message. * However, there was no documented evidence an attempt to reschedule for the missed visit was conducted for the remaining days of the week. On 3/26/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. #. The agency P&P titled Missed Visits revised 4/2021, showed if a missed visit for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. *The POC for the certification period from 12/12/24 to 2/9/25 cited SN visits 1W8 (one time a week for eight weeks) plus 2 PRN for change of condition. Review of the Missed Visit Form dated 12/31/24 and 1/14/25 showed a comments for a missed visit. However, the section for the MD notification was documented as "No". In addition, review of the clinical record failed to show documented evidenced of an attempt to re-schedule the visit for those weeks as per P&P. *The POC for the certification period from 2/10/25 to 4/10/25 cited SN visits 1W9 (one time a week for nine weeks) plus 2 PRN for change of condition. Review of the Missed Visit Form dated 2/25/25, showed a comments for a missed visit. However, the section The MD notification was documented as "No". In addition, review of the clinical record failed to show documented evidenced of an attempt to re-schedule a visit for the week as per P&P. On 3/26/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POCs included the specific information related to visit frequency, medications, and diagnosis for five of 18 sampled patients (Patients 11, 12, 13, 14, and 17). This failure had the potential for not addressing the care needs for these patients. #. Review of Patient 1’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 9/30/24. The patient was certified for home health services during the certification periods from 1/28/25 to 3/28/25. The POC, for the certification period from 1/28/25 to 3/29/25, cited SN visits 2w2 (two visits a week for two weeks) and 1w7 and OT visits 1w1 and 1-2w3. However, the visit frequency showed a range of visit instead of specific number of visits per week. On 3/26/24 at 1337 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked as to the reason for the range of SN visits. RN 1 stated each discipline who rendered services for the patient completed an assessment and they determine the frequency of the visits based on the care and needs of each patient. RN 1 was informed and acknowledged the above finding. #. Review of Patient 16’s closed clinical record was initiated on 3/25/25. The clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. The POC, for the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24, showed Patient 16 had diagnoses including COPD, oxygen dependence, and the following medications listed: - oxygen 2 liters as needed for shortness of breath - furosemide (diuretic drug) oral 20 mg two tablets daily -furosemide oral 20 mg one tablet daily The medication listed showed two furosemide orders. However, there was no specification of the time when to administer the furosemide and which should be administered first. In addition, review of the SOC OASIS dated 7/15/24, showed Patient 16 was on 2 liters of oxygen continuously. On 3/26/25 at 1318 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings. RN 1 stated the nurse should had clarified the orders with the physician. #. Review of Patient 15’s closed clinical record was initiated on 3/21/25. The clinical record showed the SOC was 7/31/24. The patient was certified for home health services during the certification periods from 7/31/24 to 9/27/24. The POC, for the certification periods from 7/31/24 to 9/27/24, cited SN visits 1w6 (one visit a week for 6 weeks), 2 prn visits for change of condition, cited PT visit for evaluation, and CHHA visits 1-2w6. The SN interventions showed for SN to administer/instruct caregiver to administer fleet enema if no bowel movement in 3-5 days. However, the medications listed in the POC did not include a fleet enema order. In addition, the POC did not include the primary/secondary diagnoses and primary language of the patient. On 3/26/25 at 1128 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledge the above finding. #. Review of Patient 6's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 9/7/22. The patient was certified for home health services during the certification periods from 12/25/24 to 2/22/25 and 2/23/25 to 4/23/25. b. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 2 to 3 W8, 1 to 2 W1 and 3 PRN for conditions/complications. However, the visit frequency showed a range of visit instead of specific number of visits per week. On 3/26/25 at 1404 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked as to the reason for the range of SN visits. The Clinical Manager replied, the visits were scheduled for three times per week, we don't have to contact the MD in that way if we have missed visit, we don't have to call the MD. The Clinical Manager was informed and acknowledged the finding. #. Review of Patient 17's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification periods from 9/28/24 to 11/26/24. The patients primary diagnosis was acute and chronic respiratory failure with hypoxia. The other diagnoses included chronic systolic (congestive ) heart failure. The POC, for the certification period from 9/28/24 to 11/26/24, cited SN visits once every other week x6, 1W1 starting 11/10/24, 3 PRN for change in condition. The POC showed the nutritional requirements included a fluid restrictions of 1500 cc/24 hours. However, review of the POC failed to include patient specific instructions/ interventions related to fluid restrictions of 1500 cc/24 hours. Further review of the POC also showed the list of medications. The medications included oxygen 2 to 5 lpm via nasal cannula continuous and PRN for SOB. However, the instructions for the use of oxygen was not specific as to what rate needed to be given for continuous and PRN use. On 3/26/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if the instructions/intervention related to fluid restrictions needed to be included in the POC. The Clinical Manager replied, it should have been included in the POC. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. Review of the POC for the certification period from 11/21/24 to 1/19/25 cited SN visits 1W9 plus 2 PRN. However, the POC failed to include specific instructions for the need of the PRN visits. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the finding. #. Review of Patient 12's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 1/24/25. The patient was certified for home health services during the certification periods from 1/24/25 to 3/24/25. *Review of the POC for the certification period from 1/24/25 to 3/24/25 cited SN visits 1W1, 1 to 2W1, 1W4, 3 PRN. However, the POC failed to include specific instructions for the need of the PRN visits. In addition, the POC showed a range of SN visits instead of specific number of visits per week. *The POC for the certification period from 1/24/24 to 3/24/25 also showed the list of medications. The medications included oxycodone HCL (opiates) 5 mg one tablet PO Q4H PRN for pain and acetaminophen oral (analgesic) 325 mg three tablets PO Q8H PRN for pain. However, there was no specific instructions as to the level of pain the patient needed to take the PRN pain medication. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 11’s clinical record showed the SOC was 1/10/25. The clinical record showed the patient received home health services during the certification period from 1/10/25 to 3/10/25. Review of the OASIS Start of Care dated 1/10/25 showed the following frequency of visits: -SN, 1w1 (one visit for week one), 2w2 (two visits for 2 weeks), 1-2w6 (one to two visits for six weeks) plus two as needed visits; -PT, 1-2w4 (one to two visits for four weeks), 1w1 (one visit for one week) starting 1/14/25; and -OT,1w1 (one visit for one week), 1-2w3 (one to two visits for three weeks) starting 1/15/25. *However, actual visits provided for the certification period 1/10/25 to 3/10/25 showed the following: -SN, one visit for week one, two visits for week two, and one visit for the succeeding weeks; -PT, two visits for four weeks, one visit for the succeeding week; -OT, one visit for one week, two visits for three weeks. Furthermore, the SN frequency of visits showed two as needed visits. However, there were no specific indication for the use of the as needed visits. On 3/26/25 at 1410 hours, an interview and concurrent clinical record review was conducted with the RN 1. The RN 1 was asked why there were a range in the visits. The RN 1 was unable to answer. The RN 1 verified the above findings. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The POC, for the certification period from 1/30/25 to 3/30/25, showed the patient’s medications included oxycodone-acetaminophen (opioid analgesic) 10-325 mg one tablet PO Q four hours PRN, oxycodone-acetaminophen 5 mg-325 mg tablet two times a day PRN, albuterol sulfate (bronchodilator) inhalation 2.5 mg/3 ml 0.083% 3 ml Q six hours PRN, and nystatin (antifungal) sprinkle two times a day. * However, there was no documented evidence of specific information when to administer oxycodone-acetaminophen 10-325 mg one tablet PO Q four hours PRN and oxycodone-acetaminophen 5 mg-325 mg tablet two times a day PRN. In addition, there was no documented evidence on the indication for the PRN use of albuterol sulfate. There was no documented on the location where nystatin sprinkle will be applied. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. Findings: 1. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The POC, for the certification period from 1/30/25 to 3/30/25, showed the patient’s medications included oxycodone-acetaminophen (opioid analgesic) 10-325 mg one tablet PO Q four hours PRN, oxycodone-acetaminophen 5 mg-325 mg tablet two times a day PRN, albuterol sulfate (bronchodilator) inhalation 2.5 mg/3 ml 0.083% 3 ml Q six hours PRN, and nystatin (antifungal) sprinkle two times a day. * However, there was no documented evidence of specific information when to administer oxycodone-acetaminophen 10-325 mg one tablet PO Q four hours PRN and oxycodone-acetaminophen 5 mg-325 mg tablet two times a day PRN. In addition, there was no documented evidence on the indication for the PRN use of albuterol sulfate. There was no documentation on the location where nystatin sprinkle will be applied. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the findings. 2. Review of Patient 11’s clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/10/25. The patient was certified for home health services during the certification period from 1/10/25 to 3/10/25. The POC, for the certification period from 1/10/25 to 3/10/25, cited SN visits 1w1 (one visit a week for one week), 2w2 (two visits a week for 2 weeks), 1-2w6 (one to two visits a week for six weeks) and two PRN visits; however, there were no specific indication for the use of the PRN visits. On 3/26/25 at 1410 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and verified the above finding. 3. Review of Patient 17's closed clinical record was initiated on 3/21/25. The clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification periods from 9/28/24 to 11/26/24. The patients primary diagnosis was acute and chronic respiratory failure with hypoxia. The other diagnoses included chronic systolic (congestive ) heart failure. The POC, for the certification period from 9/28/24 to 11/26/24, cited SN visits once every other week for six weeks, 1W1 starting 11/10/24, and 3 PRN visits for change in condition. The POC showed the nutritional requirements included a fluid restrictions of 1500 cc/24 hours; and the medications included oxygen 2 to 5 lpm via nasal cannula continuously and PRN for SOB. However, the POC failed to include patient specific instructions/ interventions related to fluid restrictions of 1500 cc/24 hours; and specific instructions on when to administer 2 lpm versus 5 lpm continuously or PRN. On 3/26/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if the instructions/intervention related to fluid restrictions needed to be included in the POC. The Clinical Manager replied, it should have been included in the POC. The Clinical Manager was informed and acknowledged the findings. 4. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. Review of the POC for the certification period from 11/21/24 to 1/19/25 cited SN visits 1W9 (one visit per week for nine weeks) and 2 PRN visits. However, the POC failed to include specific instructions for the need of the PRN visits. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the finding. 6. Review of Patient 12's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 1/24/25. The patient was certified for home health services during the certification period from 1/24/25 to 3/24/25. Review of the POC for the certification period from 1/24/25 to 3/24/25 cited SN visits 1W1, 1 to 2W1, 1W4, 3 PRN. However, the POC failed to include specific instructions for the need of the PRN visits. In addition, the POC showed a range of SN visits instead of specific number of visits per week. *The POC for the certification period from 1/24/24 to 3/24/25 also showed the list of medications. The medications included oxycodone HCL (opiates) 5 mg one tablet PO Q4H PRN for pain and acetaminophen oral (analgesic) 325 mg three tablets PO Q8H PRN for pain. However, there was no specific instructions as to the level of pain the patient needed to take the PRN pain medication. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. 7. Review of Patient 1’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 9/30/24. The patient was certified for home health services during the certification periods from 1/28/25 to 3/28/25. The POC, for the certification period from 1/28/25 to 3/29/25, cited SN visits 2w2 (two visits a week for two weeks) and 1w7 and OT visits 1w1 and 1-2w3. However, the visit frequency showed a range of visit instead of specific number of visits per week. On 3/26/24 at 1337 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked as to the reason for the range of SN visits. RN 1 stated each discipline who rendered services for the patient completed an assessment and they determine the frequency of the visits based on the care and needs of each patient. RN 1 was informed and acknowledged the above finding. 8. Review of Patient 16’s closed clinical record was initiated on 3/25/25. The clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. The POC, for the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24, showed Patient 16 had diagnoses including COPD, oxygen dependence, and the following medications listed: - oxygen 2 liters as needed for shortness of breath - furosemide (diuretic drug) oral 20 mg two tablets daily -furosemide oral 20 mg one tablet daily The medication listed showed two furosemide orders. However, there was no specification of the time when to administer the furosemide and which should be administered first. In addition, review of the SOC OASIS dated 7/15/24, showed Patient 16 was on 2 liters of oxygen continuously. On 3/26/25 at 1318 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings. RN 1 stated the nurse should had clarified the orders with the physician. 9. Review of Patient 15’s closed clinical record was initiated on 3/21/25. The clinical record showed the SOC was 7/31/24. The patient was certified for home health services during the certification periods from 7/31/24 to 9/27/24. The POC, for the certification periods from 7/31/24 to 9/27/24, cited SN visits 1w6 (one visit a week for 6 weeks), 2 prn visits for change of condition, cited PT visit for evaluation, and CHHA visits 1-2w6. The SN interventions showed for SN to administer/instruct caregiver to administer fleet enema if no bowel movement in 3-5 days. However, the medications listed in the POC did not include a fleet enema order. In addition, the POC did not include the primary/secondary diagnoses and primary language of the patient. On 3/26/25 at 1128 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledge the above finding.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded 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 verbal orders were recorded and included in the POCs for three of 18 sampled patients (Patients 2, 7, and 18). This failure had the potential risk of not addressing the care needs for these patients. #. Review of Patient 2's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 7/10/24. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/5/25. Review of SN notes dated 2/10, 2/18, 2/26, 2/28 and 3/4/25 showed patient’s left lateral foot open wound was infected and antibiotic was ordered and picked up. *However, there was no supplemental MD order for an antibiotic for the infected left lateral foot. Furthermore, SN notes dated 2/10/, 2/18, 2/26, 2/28 and 3/4/25 showed there was no medication change since last visit. On 3/26/25 at 1410 hours, an interview and concurrent clinical record review was conducted with the RN 1. The RN 1 verified there was no MD order for the antibiotic. The agency's P&P titled Physician Participation in Plan of Care revised date 11/21, showed the physician orders will be individualized based on patient's needs, and include patient diagnosis; treatments and/or procedures needed, including the type, frequency, duration and goals; medications to be administered and monitored; a description of equipment and related supplies provided by the organization; and a description of any medical, physical, psychosocial, or environmental precautions, limitation and activities permitted. #. Review of Patient 18's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/27/25. The patient was certified for home health services during the certification period from 1/27/25 to 3/27/25. The GACH’s referral to home health dated 2/9/25, showed the patient had a visit at the GACH’s ED. Documentation showed skilled nursing, PT and OT therapy for skilled assessment and strengthening/exercise. The Patient Communication dated 2/13/25, showed SN visits 1W1 then Q 14 days for supervisory aide; and CHHA 1W3 to teach family bathing techniques. Review of the SN note showed a visit was conducted on 2/13/25 and a CHHA visit was conducted on 3/5/25 * However, there was no documented evidence of a physician’s order related to the SN and CHHA’s type of services provided and the frequency of visits. On 3/26/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. #. Review of Patient 7's clinical record was initiated on 3/19/25. The clinical record showed the SOC was 1/19/24. The patient was certified for home health services during the certification periods from 1/13/25 to 3/13/25 and 3/14/25 to 5/12/25. The POC, during the certification period from 1/13/25 to 3/13/25, cited SN visits 1W9 plus two PRN visits for change in condition beginning week of 1/12/25. The SN note dated 1/15/25, showed the patient’s INR by finger stick was “1.5.” Documentation showed SN informed the physician of results. Documentation showed new Coumadin (anticoagulant) dose of 3 mg on Thursday and all other days 1.5 mg; and to recheck INR in two weeks which was week of 1/27/25. The SN note dated 1/31/25, showed the patient’s INR by finger stick was “1.7.” Documentation showed SN informed the physician of results. Documentation showed to take Coumadin 3 mg today and to continue the patient’s regular dosage of 3 mg on Thursday and all other days 1.5 mg; and to recheck INR in two weeks. The SN note dated 2/28/25, showed INR performed today (2/28/25) by finger and was “1.5.” Documentation showed the physician was informed of the INR. Documentation showed patient to take Coumadin 3 mg today then go back to regular schedule and to recheck INR in two weeks. * However, there was no documented evidence of a physician’s order for the rechecking of INR in two weeks and Coumadin dated 1/15, 1/31, and 2/28/25. On 3/26/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. Findings: The agency's P&P titled Physician Participation in Plan of Care revised date 11/21, showed the physician orders will be individualized based on patient's needs, and include patient diagnosis; treatments and/or procedures needed, including the type, frequency, duration and goals; medications to be administered and monitored; a description of equipment and related supplies provided by the organization; and a description of any medical, physical, psychosocial, or environmental precautions, limitation and activities permitted. 1. Review of Patient 18's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/27/25. The patient was certified for home health services during the certification period from 1/27/25 to 3/27/25. The GACH’s referral to home health dated 2/9/25, showed the patient had a visit at the GACH ED. Documentation showed to provide skilled nursing, PT and OT therapy for skilled assessment and strengthening/exercise. The Patient Communication dated 2/13/25, showed SN visits 1W1 then Q 14 days for supervisory aide; and CHHA 1W3 to teach family bathing techniques. Review of the SN note showed a visit was conducted on 2/13/25 and a CHHA visit was conducted on 3/5/25 * However, there was no documented evidence of a physician’s order related to the SN and CHHA’s type of services provided and the frequency of visits. On 3/26/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 2. Review of Patient 7's clinical record was initiated on 3/19/25. The clinical record showed the SOC was 1/19/24. The patient was certified for home health services during the certification periods from 1/13/25 to 3/13/25 and 3/14/25 to 5/12/25. The POC, during the certification period from 1/13/25 to 3/13/25, cited SN visits 1W9 plus two PRN visits for change in condition beginning week of 1/12/25. The SN note dated 1/15/25, showed the patient’s INR by finger stick was “1.5.” Documentation showed the SN informed the physician of the result. Documentation showed new order for Coumadin (anticoagulant) dose of 3 mg on Thursday and 1.5 mg on all other days; and to recheck INR in two weeks, which was the week of 1/27/25. The SN note dated 1/31/25, showed the patient’s INR by finger stick was “1.7.” Documentation showed the SN informed the physician of result. Documentation showed an order to take Coumadin 3 mg today and to continue the patient’s regular dosage of 3 mg on Thursday and 1.5 mg on all other days ; and to recheck INR in two weeks. The SN note dated 2/28/25, showed INR performed today (2/28/25) by finger and was “1.5.” Documentation showed the physician was informed of the INR. Documentation showed patient to take Coumadin 3 mg today then go back to regular schedule and to recheck INR in two weeks. * However, there was no documented evidence of a physician’s order for the rechecking of INR in two weeks and Coumadin dated 1/15, 1/31, and 2/28/25. On 3/26/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 3. Review of Patient 2's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 7/10/24. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/5/25. Review of SN notes dated 2/10, 2/18, 2/26, 2/28 and 3/4/25 showed patient’s left lateral foot open wound was infected and antibiotic was ordered and picked up. *However, there was no supplemental MD order for an antibiotic for the infected left lateral foot. Furthermore, SN notes dated 2/10/, 2/18, 2/26, 2/28 and 3/4/25 showed there was no medication change since last visit. On 3/26/25 at 1410 hours, an interview and concurrent clinical record review was conducted with the RN 1. The RN 1 verified there was no MD order for the antibiotic.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure wound treatment and G-tube care were provided only with a physician's order for two of 18 sampled patients (Patients 5 and13). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The POC, for the certification periods 11/21/24 to 1/19/25, cited SN visits 1W9 and 2 PRN visits for patient assessment. The SN intervention included to instruct the patient/PCG on enteral nutrition and the care/use of equipment to include the flushing of 60 ml water every feeding (30 ml) before and to give 30 ml after feeding until further orders; and bolus tube feeding of 2 Cal HN 240 ml Q6H via G-tube. a. Review of the SN notes dated 11/25, 12/2, 12/19, 12/31/24 and 1/18/25, showed the SN had completed an assessment; and the G-tube care was performed and the patient tolerated the care without pain. However, review of the clinical record failed to show documented evidence of an order for G-tube site care. b. Review of SN visit note dated 12/31/24, showed the SN had completed an assessment; and performed wound treatment to the coccyx as follows: cleanse with wound cleanser or soap and water, dry well, apply skin prep to area cover with thin hydrocolloid dressing and secure with transparent film. However, the physicians order for the treatment of the coccyx wound was obtained on 1/8/25, which was seven days after the wound was discovered. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked about an order for the G-tube site care. The Clinical Manager reviewed the clinical record and stated she did not see an order in the POC. The Clinical Manager was also asked about the wound care order. The Clinical Manager reviewed the clinical record and stated the wound care order was written on 1/8/25. The Clinical Manager was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. The POC, for the certification period from 12/12/24 to 2/9/25, cited SN visits 1W8 and 2 PRN visits for change of condition. Review of the SN visit note dated 1/25/25, showed the section of skin comments showing the SN documented a lesion on the right upper lateral arm, measuring 2.4 cm (length) x 3.9 cm (width) with scant amount of serosanguinous drainage and no odor. The SN provided wound care as follows, cleansed lesion with wound cleanser, pat dry, applied antibacterial ointment ,and covered with a 4x4 non-adherent bordered gauze dressing. However, there was no documented evidence of a physicians order for the treatment of the patient's open wound on the right upper lateral arm. A physicians order for wound care treatment was obtained on 1/27/25, two days after the SN provided the wound treatment. On 3/26/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the finding.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to revise and update the POC for one of 18 sampled patients (Patient 13). This failure created the risk for not providing the necessary care and services to these patients. #. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The OASIS E-Start of Care dated 11/22/24, showed the RN had performed comprehensive assessment. The patient was assessed to have a feeding tube (PEG). Review of the POC for the certification period from 11/21/24 to 1/19/25 cited SN visits 1W9 plus 2 PRN. The POC showed the patient nutritional requirements included an enteral feedings. However, the POC failed to be revised to address the patients PEG tube as identified of the initial comprehensive assessment. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the finding. #. Review of the agency’s P&P titled Care Planning Process revised 11/2021 showed the clinical plan of care includes pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, and nutritional requirements, food/ drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment (485) and plan of care (all disciplines). Review of 16’s closed clinical record was initiated on 3/25/25. The clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. The POC, for the certification period 7/15/24 to 9/12/24, cited SN visits1w9 (one visit a week for nine weeks), cited PT visit for an evaluation for 7/22/24, and showed primary diagnosis of right femur fracture. Review of the SN notes showed on 8/5/25, Patient 16 started complaining of pain to her right hip and the current pain management was Tylenol. However, the POC failed to show documented evidence there was pain management interventions and medications included for Patient 16. On 3/26/25 at 1136 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 stated the nurse based their interventions provided to patients on their medical history, present diagnoses, medications, wound treatments, and disease process education, and etc. RN 1 stated Patient 16’s SN interventions should have included for SN to assess for pain due to her diagnosis of right femur fracture and revised the POC to address for pain management. RN 1 was informed and acknowledged the above finding.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was notified promptly related to the changes of conditions for two of 18 sampled patients (Patients 12 and 16). This failure created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the agency’s P&P titled Monitoring Patient’s Response/Reporting to Physician revised 11/2021 showed the patient’s physician will be contacted on the same day when changes in the patient’s condition. 1. Review of Patient 12's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 1/24/25. The patient was certified for home health services during the certification periods from 1/24/25 to 3/24/25. The POC, for the certification period from 1/24/25 to 3/25/25, cited SN visits 1W1, 1-2W1, 1W4, and 3 PRN visit for assessment. Review of the SN notes dated 1/31, 2/3, 2/11, 2/18, 2/25 and 3/4/25, showed the patient was assessed to have 3+ edema ( a moderate level of swelling where a deeper pit (5 to 6 mm) remains for up to 60 seconds after pressure is applied) on the bilateral feet. However, there was no documented evidence the physician was notified. On 3/26/25 at 1058 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if the physician was notified of the patient's edema. The Clinical Manager replied no. The Clinical Manager was informed of the finding. 2. Review of 16’s closed clinical record was initiated on 3/25/25. The closed clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. The POC, for the certification period of 7/15/24 to 9/12/24, cited SN visits 1w9 and 3 prn visits for change in condition. Review of the SN notes dated 8/5/25, showed, “RN ordered mobile X-Ray of left knee swollen and painful at touch and L hip.” However, there was no documented evidence the physician was notified the same day of the patient’s change in condition as per the agency's P&P. On 3/26/25 at 1257 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the MSW and OT services were integrated in the POC for three of 18 sampled patients (Patients 5, 12, and 18). This failure created the risk of not providing quality of care and services to these patients. #. Review of Patient 18's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/27/25. The patient was certified for home health services during the certification period from 1/27/25 to 3/27/25. The GACH’s referral to home health dated 1/24/25, showed the disciplines included PT and OT therapy for strengthening/exercise. The POC, for the certification period from 1/27/25 to 3/27/25, cited PT visits 1W1 and 1-2 W8. The GACH’s referral to home health dated 2/9/25, the patient had a visit at the GACH’s ED. Documentation showed skilled nursing, PT and OT therapy for skilled assessment and strengthening/exercise. The Patient Communication dated 2/13/25, showed SN frequency 1W1 then Q 14days for supervisory visit; and PT continuing. * However, there was no documented evidence the OT services were provided to the patient. There was no documented evidence of the reason why the patient was not referred to OT services on the documentation of the GACH referral dated 1/24 and 2/9/25. On 3/26/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. #. Review of Patient 12's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 1/24/25. The patient was certified for home health services during the certification periods from 1/24/25 to 3/24/25. Review of the patient communication dated 1/24/25, showed the list of disciplines needed. The disciplines included SN, PT, OT and MSW. Review of the POC for the certification period from 1/24/25 to 3/25/25 cited SN visits, HHA, PT and OT evaluation. However, the POC failed to integrate MSW services as listed on the patient communication. On 3/26/25 at 1058 hours, an interview and clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the finding. #. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. Review of the Patient Communication notes dated 2/28/25, showed the patient was seen for OT evaluation recommended OT services 1W1, 2W3 starting 2/28/25. However, review of the clinical record failed to show documented evidenced of the physicians order for OT evaluation. On 3/26/25 at 1307 hours, an interview and clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if they needed a physicians order for OT evaluation. The Clinical Manager replied yes, there should be an order. The Clinical Manager reviewed the clinical record and replied, not seeing an order. The Clinical Manager was informed and acknowledged the finding.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the disciplines (SN, PT, OT, and CHHA) visit schedules for one of 18 sampled patients (Patient 8). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 8’s clinical record was initiated on 3/19/25. The clinical record showed SOC was 1/16/25. The patient was certified for home health services during the certification period from 1/16/25 to 3/16/25. The POC, for certification period from 1/16/25 to 3/16/25, cited SN visits 1w1, 2w1, 1w4, and 2 PRN visits for change in condition; and PT visits 1-2w8 starting 1/20/25. On 3/20/25 at 1000 hours, a joint home visit was conducted with PT 2 to Patient 8’s home. PT 2 was asked for the written instructions outlining the SN and PT visit schedule. PT 2 provided the patient’s admission packet folder. The folder contained a calendar; however, the calendar was left blank. On 3/20/25 at 1025 hours, an interview and concurrent clinical record review was conducted with PT 2. PT 2 stated he would call or text the patient the day before to confirm a visit to the patient. PT 2 stated he would inform the patient how many visits would be conducted for each week. On 3/26/25 at 1052 hours, an interview was conducted with RN 1. RN 1 stated each discipline should fill the calendar in the admission packet to give instructions to the patient of the projected days that the disciplines would provide services. RN 1 was informed and acknowledged the above findings.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to analyze and track the quality indicators to assess the processes of care as part of the QAPI program. This failure created the risk of not identifying the areas for performance improvement to improve the care and services provided to the patients. Findings: Review of the agency’s 2024 QAPI program was conducted on 3/25/25. The QAPI documents for 1st, 2nd, 3rd, and 4th quarters of 2024 showed the agency conducted the audits on areas such as admission, plan of care, PT re-evaluation, LVN supervision, medication profiles, wound measurements, CHHA services, and discharges. However, there was no documented evidence of the analysis of the data collected and tracking of areas for improvement. There was no documented evidence an action plan was developed to improve care and services. For example: The QAPI documents for the 2nd and 3rd quarters of 2024 showed an audit was conducted related to all discipline assessments completed within five days of SOC or orders/communication note “stating otherwise.” Documentation showed the result for the 2nd quarter was 0% and for the 3rd quarter was 14%. * However, there was no documented evidence the agency identified the percentage increased for not completing discipline assessments within five days of SOC or orders/communication note “stating otherwise.” There was no documented evidence action plans were developed to address this area. On 3/26/25 at 1358 hours, an interview and concurrent agency document review was conducted with the Administrator. She was informed and acknowledged the findings.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to perform the PIPs for 2023 and 2024. This created the risk of not identifying the opportunity for improvement for care and services provided to the patients. #.Review of the hospice's QAPI program for 2024 was conducted on 3/25/25. On 3/25/25 at 1545 hours, an interview and record review was conducted with the Administrator. She stated the 2024 PIPs were handwashing and UTI/catheterization. * However, there was no documented evidence of the PIP currently underway or completed for 2024. On 3/26/25 at 1358 hours, an interview and concurrent record review was conducted with the Administrator. She was informed and acknowledged the findings #. Review of the QAPI meeting minutes from the 1st, 2nd, 3rd, and 4th quarters of 2023 conducted on 3/26/25 at 0800 hours. Documentation showed the total number of occurrences. The identified occurrences were falls, infections and hospitalizations. Documentation also includes the number of patients admitted, plan of care, CHHA services and discharges. In addition, review of the QAPI documents showed a quarterly meeting was conducted. However, there were no documented evidenced of a performance improvement projects were discussed on the QAPI meeting for the year 2023. On 3/30/25 at 1422 hours, an interview and concurrent document review was conducted with the Clinical Director. The Clinical Director was asked if there were performance improvement project for the year 2023. The Clinical Manager replied, yes we do have the performance improvement but does not remember if there was one for the year 2023. The Clinical Manager was informed and acknowledged the findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the standard precautions to prevent the transmission of infections and communicable diseases were implemented for two of sampled 18 patients (Patients 2 and 4). This failure had the potential for spread of infections. #. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification periods from 2/1/25 to 4/1/25. The POC, for the certification periods from 2/1/25 to 4/1/25, cited SN visits 1-2w9 (one to two visits a week for nine weeks) and 2 prn beginning 2/2/25. In addition, the POC showed Patient 4 had a right ankle open wound. The SN interventions included for SN to perform/instruct the patient/caregiver on wound care as follows: right outer ankle trauma wound; cleanse with wound cleanser, apply Medihoney to wound bed, skin prep edges, cover with foam dressing, gauze wrap, tape, Coban two times a week and prn; patient/caregiver to perform wound care on non-SN visit days. On 3/19/25 at 1210 hours, a joint home visit was conducted with RN 3 to Patient 4’s home in an assisted living facility. RN 3 performed a wound care dressing change to Patient 4’s right ankle open wound, the following was observed: - RN 3 hand sanitized hands and donned new gloves. Prepared her wound change dressing supply and placed a clean disposable under pad under Patient 4’s right ankle. -RN 3 opened the old dressing to Patient 4’s right ankle and cleanse the wound site with normal saline spray. -RN 3 removed the old dressing and threw away the old dressing in the trash can near the bed. -RN 3 removed her gloves on both hands. RN 3 went to the Patient 4’s bathroom to look for the ointment treatment for the wound. RN 3 donned new gloves to both hands. *However, RN 3 did not perform hand hygiene or handwashing in between change of gloves. -RN 3 applied ointment to Patient 4’s right ankle open wound and wrap it with dry dressing and Coban wrap. -RN 3 removed all the remaining supplies and threw in the trash. RN 3 removed gloves on both hands. RN 3 donned new gloves again without performing hand hygiene or handwashing in between change of gloves. On 3/19/25 at 1245 hours, an interview was conducted with RN 3. RN 3 was informed and acknowledged the above finding. On 3/26/25 at 1035 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the above finding. #. According to the CDC recommendation, washing hands before and after using gloves to prevent the spread of germs. If soap and water are not available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. Gloves are not a substitute for hand hygiene. Review of Patient 2's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 7/10/24. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/5/25. A joint home visit with the RN 2 was conducted on 3/19/25 at 1100 hours, to Patient 2’s home. The following was observed: The RN 2 put on gloves, removed the old dressing for the left lateral foot and left 5th toe, cleanse with cleanser, pat dry, applied gentamicin, calcium alginate, zinc oxide in the peri-wound, gauze and applied adhesive dressing, then removed gloves. *However, RN 2 put on and removed gloves without washing hands or using alcohol-based sanitizer before the start and after completion of the wound care. Furthermore, RN 2 did not change gloves after removing the old wound dressing. The RN 2 acknowledged the above findings. On 3/26/25 at 1410 hours, an interview was conducted with the RN 1. The RN 1 was informed and acknowledged of the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement and maintain the infection control program which included prevention, action plan and control of infections. This failure had the potential for spread of infections. #. The agency P&P titled Evaluating and Maintaining Records of Infections among patients revised 11/2021, showed the procedure includes each section of the report should be completed in its entirety. Review of the infection control documents from the 1st, 2nd, 3rd and 4th quarters of 2023 was conducted on 3/25/25 at 1350 hours. The following were identified: -The 1st Quarter of 2023 showed the Infection log. The list showed a total of 13 patients were identified. The identified patients showed the patient information, infection information, infection actions and communications and treatment notes. However, review of the two identified patient list failed to include the treatment provided as per P&P. Further review of the Infection Log, showed a summary of the total numbers of infection, The summary included the cases Urinary = 6, Cellulitis = 3, respiratory= 3 and Other = 1 However, the list of patient data collected showed the number of cases for Cellulitis was 2 instead of 3 and the respiratory cases were 2 instead of 3 which was inconsistent. In addition, review of the log showed an Infection Control Plan and Interpretation of the Risk Analysis. The interpretation included based on the analysis for the priority risk, the following infections are to be watched for prevention of increased on rate will be planned for UTI, Respiratory and Cellulitis. However, the log failed to include specific action plans and intervention to address the infections identified for the quarter. -The 2nd Quarter Infection log showed a total of nine patients. However, three of the identified patients failed to include the treatment provided as per P&P. In addition, review of the log showed an Infection Control Plan and Interpretation of the Risk Analysis. The interpretation included based on the analysis for the priority risk, the following infections are to be watched for prevention of increased on rate will be planned for UTI and Cellulitis. Further review of the Infection Log, showed a summary of the total numbers of infection, The summary included the cases Urinary = 8, Cellulitis = 1 and Other = 1. However, the log failed to include specific action plans and intervention to address the increase cases of UTI as identified for the quarter. -The 3rd Quarter Infection log showed a total of six patients. However, two of the identified patients failed to include the treatment provided as per P&P. In addition, review of the log showed an Infection Control Plan and Interpretation of the Risk Analysis. The interpretation included based on the analysis for the priority risk, the following infections are to be watched for prevention of increased on rate will be planned for Cellulitis and UTI. However, the log failed to include specific action plans and intervention to address the infections identified for the quarter. -The 4rth Quarter Infection log showed a total of five patients. However, two of the identified patients failed to include the treatment provided as per P&P. In addition, review of the log showed an Infection Control Plan and Interpretation of the Risk Analysis. The interpretation included based on the analysis for the priority risk, the following infections are to be watched for prevention of increased on rate will be planned for Cellulitis an UTI. Further review of the Infection Log, showed a summary of the total numbers of infection, The summary included the cases of Cellulitis = 5 and Urinary =2 However, the log failed to include specific action plans and intervention to address the increase rate of cellulitis as identified for the quarter. On 3/30/25 at 1422 hours, an interview and concurrent document record review was conducted with the Clinical Manager. The Clinical Manager was asked as to the total cases of cellulitis on the first quarter. The Clinical Manager reviewed the infection log and replied, it doesn't match, we made a mistake, it should be 2 cases instead of 3. The Clinical Manager was also asked as to the plans to address increase cases of the identified infections. The Clinical Manager replied, we provide in-services such has handwashing and wound care treatment. The Clinical Manager was further asked if they needed to document the treatment provided in the patients infection log. The Clinical Manager replied, it should be completed. The Clinical Manager was informed and acknowledged the findings. Review of the agency's P&P titled Infection Prevention and Control: Evaluating and Maintaining Records of Infections Among Patients revised date 11/21, showed the following: -All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery. If trends are discovered, target surveillance or problem-oriented surveillance may be initiated for specific high-risk patient populations if high volume, problem-prone areas are identified. -The Infection Identification Patient Report Form is completed when any of the following occur: A. A new, actual, or suspected infection is clinically observed by home health personnel B. A culture is ordered and performed, and the results are positive C. A new antibiotic is ordered D. A patient is admitted to a hospital due to an actual or suspected infection E. An unanticipated death due to an actual or suspected infection F. A major permanent loss of function associated with an actual or suspected infection G. A reportable, communicable infection is identified H. Patient has temperatures greater than 101 degrees F I. Patient has conjunctivitis -The Case Manager or nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection. -Each section of the report should be completed in its entirety. -After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up. -The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The break down and summary may include but will not be limited to: a. Number of infection types b. Sources of infection c. Diagnoses d. age/sex of patients e. Family/caregiver f. Pathogens, if identified g. Follow-up taken -The Performance Improvement Coordinator or designee, in conjunction with the Clinical Manager, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations. -A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the appropriate Professional Advisory Committee. -Information from the summary, analysis, and discussion will be used as part of the organization's risk analysis and annual evaluation of the organization's infection prevention and control activities. 1. Review of the infection control documents from the 1st, 2nd, 3rd, and 4th quarters of 2024 was conducted on 3/25/24. a. Some of the individual Infection Control Log was not completed. For example: The individual Infection Log of Patient D showed the patient had a urinary infection with the onset date of 4/6/24. Documentation showed the patient had burning with urgency upon urination. The individual Infection Log of Patient E showed the patient had surgical wound cellulitis with the onset date of 7/23/24. Documentation showed signs and symptoms included redness, swelling, and painful to touch. * However, the Treatment Notes of Patient D and E in the document were blank. b. There was no documented evidence of action plans to control and minimize infections. For example: The 2024 1st quarter infection control document showed there were six urinary infection cases and one cellulitis infection case. The 2024 2nd quarter infection control document showed there were eight urinary infection cases, one cellulitis infection case, and one respiratory infection case. The 2024 2nd quarter Infection Control Plan and Interpretation of the Risk Analysis Table showed based on the analysis of the priority risk the following infections are to be watched for and prevention of increased on rate will be planned: UTI, respiratory, and cellulitis. * However, there was no documented evidence of actions plans developed to address the increase in the number of urinary infection cases and the incidence of respiratory infection case for the 2nd quarter of 2024. On 3/26/25 at 1330 hours, an interview and concurrent record review was conducted with the Administrator. She was informed and acknowledged the findings. Findings: 1. The agency's P&P titled Evaluating and Maintaining Records of Infections among patients revised 11/2021 showed the procedure includes each section of the report should be completed in its entirety. Review of the infection control documents from the 1st, 2nd, 3rd and 4th quarters of 2023 were conducted on 3/25/25 at 1350 hours. The following was identified: -The 1st Quarter of 2023 Infection log showed a total of 13 patients was identified. The identified patients showed the patient information, infection information, infection actions, and communications and treatment notes. However, review of the two identified patient lists failed to include the treatment provided as per the agency's P&P. The Infection Log showed the following cases: urinary = 6, cellulitis = 3, respiratory= 3, and other = 1. However, the list of patient data collected were inconsistent with the summary wherein cases for cellulitis was 2 instead of 3 and the respiratory cases were 2 instead of 3. The Infection Control Plan and Interpretation of the Risk Analysis showed based on the analysis of the priority risk, the following infections were to be watched for for and prevention of increased rate will be planned: UTI, respiratory and cellulitis. However, the log failed to include specific action plans and intervention to address the infections identified for the quarter. -The 2nd Quarter Infection log showed a total of nine patients. However, three of the identified patients failed to include the treatment provided as per the agency's P&P. The Infection Control Plan and Interpretation of the Risk Analysis showed based on the analysis for the priority risk, the following infections were to be watched for and prevention of increased rate will be planned: UTI and cellulitis. The Infection Log showed the total numbers of infection were as follows: urinary = 8, cellulitis = 1, and other = 1. However, the log failed to include specific action plans and intervention to address the increase cases of UTI as identified for the quarter. -The 3rd Quarter Infection log showed a total of six patients. However, two of the identified patients listed did not have the treatment documented as per the agency's P&P. The Infection Control Plan and Interpretation of the Risk Analysis showed based on the analysis for the priority risk, the following infections were to be watched for and prevention of increased on rate will be planned: cellulitis and UTI. However, the log failed to include specific action plans and intervention to address the infections identified for the quarter. -The 4th Quarter Infection log showed a total of five patients. However, two of the identified patients listed did not have the treatment documented as per the agency's P&P. The Infection Control Plan and Interpretation of the Risk Analysis showed based on the analysis for the priority risk, the following infections were to be watched for: cellulitis and UTI. Further review of the Infection Log showed the total number of infections were as follows: cellulitis = 5 and urinary = 2. However, the log failed to include specific action plans and intervention to address the increased rate of cellulitis as identified for the quarter. On 3/30/25 at 1422 hours, an interview and concurrent agency document review was conducted with the Clinical Manager. The Clinical Manager was asked regarding the total cases of cellulitis on the first quarter. The Clinical Manager reviewed the infection log and stated it did not match and it should be 2 cases instead of 3 cases. The Clinical Manager was also asked as to the plans to address increase cases of the identified infections. The Clinical Manager stated they provided in-services, such has handwashing and wound care treatment. The Clinical Manager was further asked if they needed to document the treatment provided in the patients infection log. The Clinical Manager stated it should be completed. The Clinical Manager was informed and acknowledged the findings. 2. Review of the agency's P&P titled Infection Prevention and Control: Evaluating and Maintaining Records of Infections Among Patients revised date 11/21 showed the following: -All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery. If trends are discovered, target surveillance or problem-oriented surveillance may be initiated for specific high-risk patient populations if high volume, problem-prone areas are identified. -The Infection Identification Patient Report Form is completed when any of the following occur: A. A new, actual, or suspected infection is clinically observed by home health personnel B. A culture is ordered and performed, and the results are positive C. A new antibiotic is ordered D. A patient is admitted to a hospital due to an actual or suspected infection E. An unanticipated death due to an actual or suspected infection F. A major permanent loss of function associated with an actual or suspected infection G. A reportable, communicable infection is identified H. Patient has temperatures greater than 101 degrees F I. Patient has conjunctivitis -The Case Manager or nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection. -Each section of the report should be completed in its entirety. -After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up. -The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The break down and summary may include but will not be limited to: a. Number of infection types b. Sources of infection c. Diagnoses d. age/sex of patients e. Family/caregiver f. Pathogens, if identified g. Follow-up taken -The Performance Improvement Coordinator or designee, in conjunction with the Clinical Manager, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations. -A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the appropriate Professional Advisory Committee. -Information from the summary, analysis, and discussion will be used as part of the organization's risk analysis and annual evaluation of the organization's infection prevention and control activities. 1. Review of the infection control documents from the 1st, 2nd, 3rd, and 4th quarters of 2024 was conducted on 3/25/24. a. Some of the individual Infection Control Log was not completed. For example: The individual Infection Log of Patient D showed the patient had a urinary infection with the onset date of 4/6/24. Documentation showed the patient had burning with urgency upon urination. The individual Infection Log of Patient E showed the patient had surgical wound cellulitis with the onset date of 7/23/24. Documentation showed signs and symptoms included redness, swelling, and painful to touch. * However, the Treatment Notes of Patient D and E in the document were blank. b. There was no documented evidence of action plans to control and minimize infections. For example: The 2024 1st quarter infection control document showed there were six urinary infection cases and one cellulitis infection case. The 2024 2nd quarter infection control document showed there were eight urinary infection cases, one cellulitis infection case, and one respiratory infection case. The 2024 2nd quarter Infection Control Plan and Interpretation of the Risk Analysis Table showed based on the analysis of the priority risk the following infections are to be watched for and prevention of increased on rate will be planned: UTI, respiratory, and cellulitis. * However, there was no documented evidence of actions plans developed to address the increase in the number of urinary infection cases and the incidence of respiratory infection case for the 2nd quarter of 2024. On 3/26/25 at 1330 hours, an interview and concurrent record review was conducted with the Administrator. She was informed and acknowledged the findings.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide the annual infection control training to their personnel. This failure created the risk of not providing quality of care and service to the patients receiving services from HHA. Findings: The agency’s P&P title Infection Control Plan revised 11/2021 showed the agency will educate all personnel on infection control policies, procedures, and their responsibilities. Personnel will be provided training on the basics of transmission of pathogens to the patients and staff, bloodborne diseases, the use of standard precautions, infectious waste management, and other infection control procedures when their work activities may result in an exposure to blood, other potentially infectious materials, or under circumstances in which differentiation between body fluid types is difficult or impossible. Infection control inservices will be scheduled no less than annually. Attendance will be mandatory and will be documented. Review of the personnel files for RNs 2, 3, 4, 5, LVNs 1 and 2, and CHHAs 1 and 2 were conducted on 3/25/25. The personnel files failed to show documented evidenced for the annual infection control for these employees. On 3/26/25 at 1330 hours, an interview and concurrent document review was conducted with the HR staff. The HR staff verified there was no updated annual infection control training provided to the personnel.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patients received care and services as per the written plans of care for nine of 18 sampled patients (Patients 1, 2, 4, 5, 7, 10, 13, 14, and 17 ). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: #. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification periods from 2/1/25 to 4/1/25. The POC, for the certification period from 2/1/25 to 4/1/25, showed Patient 4 had a right ankle open wound. Cited SN visits for 1-2w9 (one to two visits a week for nine weeks) and 2 prn beginning 2/2/25. The SN interventions showed SN to assess/evaluate wound(s) at each dressing change and prn for signs/symptoms of infection. Review of Patient 4’s SN visit notes dated 2/4, 2/6, 2/14, 2/17, and 2/21/25, showed RN 3 performed an intervention of wound care dressing change to Patient 4’s right outer ankle wound. However, the SN visit notes failed to show documented evidence RN 3 had assessed or evaluated Patient 4’s right outer ankle wound. On 3/26/25 at 1032 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding. #. Review of Patient 17's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification periods from 9/28/24 to 11/26/24. The patients primary diagnosis was acute and chronic respiratory failure with hypoxia. The other diagnoses included chronic systolic (congestive ) heart failure. The POC, for the certification period from 9/28/24 to 11/26/24, cited SN visits once every other week x6, 1W1 starting 11/10/24, 3 PRN for change in condition. The POC showed the nutritional requirements included a supplement- Ensure and a fluid restrictions of 1500 cc/24 hours. The interventions included SN to instruct on signs and symptoms of dehydration. The POC also showed SN to assess temperature, pulse, respiratory rate and BP each visit and notify physician for oxygen saturation less than 85%. *Review of the SN visit note dated 10/10/24, showed the SN had taken the patients temperature, pulse, respiratory rate. However, the section for the patients BP was left blank. *Review of the SN visit note dated 10/23/24, showed the SN had performed a body system assessment. The assessment included the level of oxygen saturation. The oxygen saturation was documented as 84% RA. However, review of the clinical record failed to show documented evidenced of the SN had re-checked the patients oxygen saturation. In addition, the physician was not notified related to low oxygen saturation as the section on physician contacted was documented as "No". *Review of SN visit notes dated 11/12/24, showed the SN had performed a body system assessment. However, the section for pain was left blank. *Review of the SN notes dated 10/10, 10/23, 11/13 and 11/25/24, showed the SN had performed an assessment. The assessment included a checked marked on the section of meals prepared and administered appropriately. However, review of the SN visit notes failed to show documented evidenced of the patients was provided the supplement ensure. In addition, there were no documented evidenced of the patients fluid restrictions of 1500 cc/24 hours. On 3/26/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager reviewed the notes and acknowledged the findings. #. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. a. The POC, for the certification period from 1/20/25 to 3/20/25, cited SN visits 2W1 then hospitalized. The POC showed the nutritional requirement includes enteral nutrition Two Cal (formula) 240 cc Q6H via pump. The SN intervention included to instruct the patient/PCG on enteral nutrition and the care/use of equipment to include the flushing of 60 ml water every feeding (30 ml) before and to give 30 ml after feeding until further orders. Bolus TF (2 Cal HN) 240 ml Q6H via G-Tube. The SN intervention also included SN to instruct patient on daily weight self monitoring program and to log weight. SN to assess patient weight log every visit. Review of the SN notes dated1/20/25, showed the SN had performed an assessment. The assessment included a section for Tube Feeding. However, the section was left blank. In addition, review of the SN notes failed to show documented evidenced of the tube feeding and flushing was provided. Further, the SN failed to assess the patient weight log as the section for weight was left blank. On 3/26/25 at 1121 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if the tube feeding and flushing was provided. The Clinical Manager reviewed the clinical record and replied, the PCG was giving the tube feeding. The Clinical Manager was also asked if there was a documentation of the PCG provided the tube feeding. The Clinical Manager replied, it should have been documented. The Clinical Manager was further asked if the patients weight was taken. The Clinical Manager replied, not done. The Clinical Manager was informed and acknowledged the findings. crossed ref G- 714 b. The POC, for the certification period from 11/21/24 to 1/19/25, cited SN visits 1W9 plus 2 PRN for patient assessment. The POC showed the nutritional requirement includes enteral nutrition Two Cal (formula) 240 cc Q6H via pump. The SN intervention included to instruct the patient/PCG on enteral nutrition and the care/use of equipment to include the flushing of 60 ml water every feeding (30 ml) before and to give 30 ml after feeding until further orders. Bolus TF (2 Cal HN) 240 ml Q6H via G-Tube. The SN intervention also included SN to instruct patient on daily weight self monitoring program and to log weight. SN to assess patient weight log every visit. *Review of the SN visit notes dated 12/19/25, showed the SN had performed an assessment. The assessment included the patients weight. However, review of the SN notes dated 11/25, 12/2, 12/31 and 1/8/25 failed to show documented evidenced of the patient weight was taken. In addition, there was no documentation of the patient weight log was checked as ordered on the POC. *Review of the SN notes dated 11/25, 12/2, 12/31/24 and 1/8/25, showed the SN had performed an assessment. However, review of the clinical record failed to show documented evidenced of the SN had performed an instructions related to tube feeding and flushing as ordered in the POC. *The POC, for the certification period from 11/21/24 to 1/19/25 also cited for OT evaluation. However, review of the clinical record failed to show documented evidenced of the OT evaluation was completed as ordered in the POC. On 3/26/25 at 1155 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. The POC for the certification period from 2/10/25 to 4/10/25 cited SN visits 1W9 plus r PRN for change of condition. The POC includes SN to assess skin for breakdown. SN to assess/evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. Review of the SN visit notes dated 2/13 and 3/3/25, showed the SN had documented three open wound located at the right lateral arm. However, the SN failed to performed a wound assessment as ordered in the POC. In addition, review of the SN notes dated, 2/21 and 3/13/25, showed the SN had performed skin assessment. However, the SN failed to performed wound assessment as ordered in the POC. On 3/26/25 at 1307 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked as to the frequency of the wound assessment. The Clinical Manager replied, every SN visit. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The POC, for the certification period from 1/30/25 to 3/30/25, cited SN visit 2-3 W8, 1W1, and 3 PRN visits for change in condition. The POC showed the following information: -Oxygen at 3 liters per minute continuous. -SN to perform wound care as follows on the low back surgical site by cleansing with wound cleanser, pat dry, apply calcium alginate (wound dressing), cover with dry adhesive dressing each visit. a. The SN Notes dated 2/1, 2/3, 2/5, 2/7, 2/8, 2/10, 2/11, 2/14, 2/17, 2/19, 2/20, 2/21, 2/24, 2/26, 2/28, 3/3, 3/5, 3/7, and 3/12/25, showed the patient was on oxygen at 2 liters per minute instead of 3 liters per minute as per the POC. b. The SN notes dated 2/1 and 2/26/25, showed no documented evidence the SN performed treatment on the patient’s low back surgical site. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. #. Review of Patient 7's clinical record was initiated on 3/19/25. The clinical record showed the SOC was 1/19/24. The patient was certified for home health services during the certification periods from 1/13/25 to 3/13/25 and 3/14/25 to 5/12/25. The POC, during the certification period from 1/13/25 to 3/13/25, cited SN visits 1W9 plus two PRN visits for change in condition beginning week of 1/12/25. Documentation showed to assess patient’s weight log every visit. * However, there was no documented evidence the patient’s weight log was assessed every visit as per the POC. On 3/26/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. #. Review of Patient 10's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 2/7/25. The patient was certified for home health services during the certification periods from 2/7/25 to 4/7/25. The POC, during the certification period from 2/7/25 to 4/7/25, cited SN visits 1W1, 2W3, 1W5 plus 2 PRN with change in condition. The POC showed the following: -SN to assess patient’s weight log every visit. -SN to perform/instruct patient/caregiver on wound care as follows: cleanse right dorsal foot with wound cleanser or NS, cover with “Polymen/foam silver dressing” (wound dressing), wrap with gauze and tape two times a week and PRN with soiling until healed. a. The SN note dated 2/10, 2/13, 2/27, 2/20, 3/5, and 3/12/25, showed no documented evidence the patient’s weight log was assessed. b. The SN note dated 2/13 and 2/17/25, showed new wound care order performed by cleansing right dorsal foot wound with wound cleanser, cover with foam dressing, and may use calcium alginate if draining. * However, there was no documented evidence of a physician’s order to cleanse right dorsal foot wound with wound cleanser, cover with foam dressing, and may use calcium alginate if draining at the above dates. On 3/26/25 at 1317 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. #. Review of the agency’s P&P titled Care Planning Process revised 11/2021 showed the clinical plan of care includes pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment and plans of care. The plan of care will be based upon the physician’s orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Review of Patient 2’s clinical record showed SOC was 7/10/24. The clinical record showed the patient received home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/6/25. a. An MD order dated 2/24/25 showed left lateral foot open wound to cleanse with wound cleanser and pat dry, apply collagen particles and gentamicin ointment for prophylaxis, zinc oxide cream to peri-wound, cover with gauze and apply adhesive dry dressing. Review of SN Wound Care Notes dated 2/28/25, showed the SN performed wound care to the left lateral foot open wound. * However, the SN documented cleaning with wound cleanser, pat dry, applied medihoney, abdominal pad, wrapped with kerlix and secured with tape. b. An MD order dated 3/18/25 showed a wound care order for the left 5th toe and left lateral foot to cleanse with NSS, pat dry, apply gentamicin ointment, then calcium alginate, cover with gauze, then cover with bordered gauze. Change dressings daily and as needed for soilage and loss of integrity. A joint home visit with the RN 2 was conducted on 3/19/25 at 1100 hours, to Patient 2’s home. The RN 2 was observed performing wound care to Patient 2. *However, RN 2 provided wound care treatment to Patient 2’s left lateral foot and left foot 5th toe by cleansing the locations with NSS, pat dry, applied gentamicin, then calcium alginate and applied zinc oxide in the peri-wound, covered with gauze and bordered gauze. The RN 2 acknowledged the above findings. c. Review of the agency’s P&P titled Wound Care Procedure revised 11/2021 showed wounds are to be measured weekly with a picture uploaded in patient’s file. The POC for certification period from 1/6/25 to 3/6/25 and 3/7/25 to 5/5/25, both showed clinician to assess skin for breakdown and SN to assess/evaluate wound(s) at each dressing change and as needed for signs/symptoms of infection. Review of the SN Wound Care notes for 2/5, 2/6, 2/7,2/10,2/12/, 2/14, 2/18, 2/19, 2/21, 2/26 and 2/28/25 failed to show documented evidence the wound in left lateral foot and left 5th toe was measured. On 3/26/25 at 1410 hours, an interview and concurrent clinical review was conducted with RN 1. RN 1 verified the above findings.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and or caregiver was provided education related to fluid restrictions as per the plan of care for two of 18 sampled patients (Patients 13 and 17). This failure had the potential for not providing the necessary care and services to this patient. 1. Review of Patient 17's closed clinical record was initiated on 3/21/25. The closed clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification period from 9/28/24 to 11/26/24. The patient's primary diagnosis was acute and chronic respiratory failure with hypoxia. The other diagnoses included chronic systolic (congestive ) heart failure. The POC, for the certification period from 9/28/24 to 11/26/24, cited SN visits once every other week x6, 1W1 starting 11/10/24, 3 PRN visits for change in condition. The POC showed the nutritional requirements included a fluid restrictions of 1500 cc/24 hours. The POC also includes SN to instruct on signs and symptoms of dehydration. The SN notes dated 10/10, 10/23, and11/12/24, showed the SN had instructed the patient to include signs and symptoms of congestive heart failure and dehydration. However, review of the SN visit notes failed to include the patient specific instructions/interventions related to fluid restrictions of 1500 cc/24 hours. On 3/26/25 at 1008 hours, an interview and concurrent closed clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if the patient/PCG was provided education related to the fluid restrictions. The Clinical Manager replied none was documented. The Clinical Manager was informed and acknowledged the findings. 2. Review of Patient 13's closed clinical record was initiated on 3/18/25. The closed clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The POC, for the certification period from 1/20/25 to 3/20/25, cited SN visits 2W1 then hospitalized. The POC showed the nutritional requirement includes enteral nutrition Two Cal (formula) 240 cc Q6H via pump. The SN intervention included to instruct the patient/PCG on enteral nutrition and the care/use of equipment included the flushing of 60 ml water every feeding (30 ml) before and to give 30 ml after feeding until further orders; and to provide bolus TF (2 Cal HN) 240 ml Q6H via G-Tube. The SN intervention also included SN to instruct the patient on daily weight self monitoring program and to log weight and SN to assess the patient weight log every visit. Review of the SN note dated1/20/25, showed the SN had performed an assessment. The SN note included a goal summary which included the patient/caregiver will demonstrate proper care/use of enteral nutrition equipment by three to four weeks. However, the goals and intervention failed to show the patient/caregiver would be provided an instructions related to tube feeding and flushing, and daily weight self monitoring and weight log. On 3/26/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if an instruction for tube feeding and flushing was provided. The Clinical Manager reviewed the clinical record and stated it should have been documented. The Clinical Manager was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals had accurately prepared the clinical notes for 11 of 18 sampled patients (Patients 1, 2, 4, 5, 6, 10, 12, 13, 14, 17, and 18). This failure had the potential for substandard healthcare outcomes to these patients. Findings: #. Review of the agency’s P&P titled Contents of the Clinical Record revised 11/2021 showed the clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. Signed and dated progress notes for each discipline rending service. Clinical notes shall be signed and incorporated into the patient’s health record at least every seven working days. Review of Patient 1’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 9/30/24. The patient was certified for home health services during the certification periods from 1/28/25 to 3/28/25. The POC, for the certification period from 1/28/25 to 3/29/25, cited PT visits for 1-2w8 (one to two visits a week for eight weeks). Review of Patient 1’s PT notes showed “not started” on 3/4, 3/6, and 3/11/25. On 3/18/25 at 1415 hours, an interview and concurrent clinical record review was conducted with the Administrator. When the Administrator was asked to show Patient’s 1 PT notes for 3/4, 3/6, and 3/11/25, she verified the PT notes were entered by the assigned PT on 3/18/25 at 1328 hours. The Administrator showed the submission audit log for each PT notes which showed the PT notes with the dates above were entered more than seven working days of when the service was rendered. The Administrator was informed and acknowledged the above finding. #. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification periods from 2/1/25 to 4/1/25. The POC, for the certification period from 2/1/25 to 4/1/25, showed to notify the physician if the systolic BP was greater than 160 or less than 90 mmHg and if the diastolic BP was greater than 90 or less than 50 mmHg. Review of the SN notes dated 3/14/25, showed a BP reading of systolic BP of 123 mmHg measurement. However, the diastolic BP measurement was left blank. On 3/26/25 at 1034 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding. #. Review of Patient 6's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 9/7/22. The patient was certified for home health services during the certification periods from 12/25/24 to 2/22/25 and 2/23/25 to 4/23/25. The primary diagnosis was encounter for attention to ileostomy. a. Review of the Case Conference dated 1/21 and 2/18/25 on the section of current medical necessity and team coordination showed patient continues to require SN visits for colostomy care and maintenance. However, the patient diagnosis was for attention to ileostomy instead of colostomy. b. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 2 to 3 W8, 1 to 2 W1 and 3 PRN for conditions/complications. Review of the SN notes dated 12/25, 12/27, 12/30, 1/2, 1/4, 1/6, 1/13, 1/15, 1/17, 1/20, 1/22, 1/24, 1/27, 1/29, 1/31, 2/3, 2/5, 2/7, 2/10, 2/12, 2/14, 2/17, 2/19 and 2/21/25 showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with the patient's activity or movement = patient has no pain or does not interfere with activity, - the primary site = fingers, - pain intensity = 3, - current pain management and effectiveness = does not take pain medication - what makes the pain worse = ADL's. However, the section of the frequency of pain interfering with the patient's activity or movement showed patient has no pain which was inconsistent. c. The POC, for the certification period from 2/23/25 to 4/23/25, cited SN visits 2 to 3 W9 and 3 PRN for conditions/complications. Review of the SN notes dated 2/24, 2/26, 2/28, 3/1, and 3/3/25 showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with the patient's activity or movement = patient has no pain or does not interfere with activity, - the primary site = fingers, - pain intensity = 3, - current pain management and effectiveness = does not take pain medication - what makes the pain worse = ADL's. In addition, review of the SN visit notes dated 3/5, 3/7, 3/10, 3/12 and 3/14/25, showed the patients pain intensity was 4. However, the section of the frequency of pain interfering with the patient's activity or movement showed patient has no pain which was inconsistent. d. Review of the SN visit calendar for the certification periods from 2/23/25 to 4/23/25 showed the assigned SN, target date, visit date, status and miscellaneous. The SN visit dates from 3/5, 3/7, 3/10/25 , 3/12, 3/14 and 3/17/25 showed the status was not started, colored red. On 3/30/25 at 1300 hours, the Administrator was asked to provide the audit trail for the SN visit notes starting from 3/5/25. The Administrator provided the task audit for the charts. Review of the Task Details dated 3/5, 3/7, 3/10, 3/12 and 3/14/25 showed the SN submitted the visit notes on 3/20/25. On 3/26/25 at 1526 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if there was an SN missed visits on Week 3 and Week 4. The Clinical Manager replied, there was a visit but the SN submitted the notes late. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 17's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification periods from 9/28/24 to 11/26/24. The patients primary diagnosis was acute and chronic respiratory failure with hypoxia. The other diagnoses included chronic systolic (congestive ) heart failure. The POC, for the certification period from 9/28/24 to 11/26/24, cited SN visits once every other week x6, 1W1 starting 11/10/24, 3 PRN for change in condition. *Review of the SN visit note dated 10/10, 10/23 and 11/12/24/24, showed the SN had performed an assessment. The assessment included the patients weight. However, the SN documented the patients weight as "same". On 3/26/24 at 1008 hours an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked as to the meaning of "same". The Clinical Manager reviewed the clinical record and replied, it should be specific. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The POC, for the certification period from 1/20/25 to 3/20/25, cited SN visits 2W1 then hospitalized. HHA 2W9 beginning of week 1/19/25 and PT evaluation. Review of the Patient communication dated 1/23/24, showed OT evaluation was not completed. However, there was no order for OT. On 3/26/25 at 1121 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if there was on order for OT. The Clinical Manager reviewed the clinical record and replied, don't see an order, the patient went to the hospital, it was a charting error. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The POC for the certification periods 11/21/24 to 1/19/25 cited SN visits 1W9 plus 2 PRN for patient assessment. Review of SN visit note dated 12/31/24, showed the SN had performed an assessment. The interventions performed included a wound treatment to the coccyx. The SN to perform/instruct caregiver to clean affected area of coccyx with wound cleanser or soap and water, dry well, apply skin prep to area cover with thin hydrocolloid dressing and secure with transparent film. However, review of the clinical record showed a check marked on WNL on the section of skin assessment which was inaccurate. In addition, review of the SN notes dated 11/25, 12/2, 12/19, 12/31/24 and 1/8/25, showed the SN had provided G-tube care. However, the SN documented the patients skin as WNL which was inaccurate. On 3/26/25 at 1155 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed of the findings. #. Review of Patient 12's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 1/24/25. The patient was certified for home health services during the certification periods from 1/24/25 to 3/24/25. Review of the POC for the certification period from 1/24/25 to 3/24/25 cited SN visits 1W1, 1 to 2W1, 1W4, 3 PRN. The POC showed the primary diagnosis was encounter for other orthopedic aftercare. The interventions include SN to assess pain level and effectiveness of pain medications and current pain management every visit. Review of the SN notes dated 1/28/25, showed the SN had performed pain assessment. The pain assessment includes the following: - frequency of pain interfering with the patient's activity or movement = daily but not constantly, - the primary site = posterior neck, - pain intensity = 7, - current pain management and effectiveness = medication, rest - what makes the pain worse = movement. However, review of the SN notes dated 1/312/3, 2/11, 2/18, 3/25 and 3/4/25 failed to show the SN had performed completed pain assessment as the section for "what makes the pain worse" was left blank. On 3/26/25 at 1058 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. a. The POC for the certification period from 12/12/24 to 2/9/25 cited SN visits 1W8 (one time a week for eight weeks) plus 2 PRN for change of condition. Review of the SN visit note dated1/25 and 2/7/25 on the section of skin comments showed the SN documented a lesion on the right upper lateral arm, measuring 2.4 cm x 3.9 cm with scant amount of serosanguinous drainage, no odor. The SN provided wound care as follows, cleansed lesion with wound care cleanser, pat dry, applied antibacterial ointment and covered with a 4x4 non-adherent bordered gauze dressing. However, on the section of skin assessment showed the SN marked the skin as WNL which was inconsistent. b. The POC for the certification period from 2/10/25 to 4/10/25 cited SN visits 1W9 (one time a week for nine weeks) plus 2 PRN for change of condition. Review of the SN visit note dated 2/13 and 3/3/25, showed the SN had documented an open wound to the patients right lateral arm. The documentation showed an open wound 1, 2 and 3 located at the right lateral arm. The Wound 3 was assessed as to the status of wound, measurement, color, drainage, odor and surrounding tissue. However, on the section for the skin assessment showed the SN marked the skin as WNL which was inconsistent. On 1336 hours, an interview and concurrent clinical record review was conducted with the Clinical Director. The Clinical Director was informed of the findings. #. Review of Patient 2’s clinical record showed SOC was 7/10/24. The clinical record showed the patient received home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/6/25. a.The POC, for the certification period from 1/6/25 to 3/6/25, showed SN to perform wound care to left lateral foot open wound cleanse with wound cleanser and pat dry apply santyl and gauze at each visit. An MD order on 2/18/25, showed a new wound care order for the left lateral foot to cleanse with wound cleanser and pat dry, apply collagen powder and gentamicin ointment, apply barrier cream around the peri-wound to help protect site from maceration, cover with gauze and apply dry adhesive dressing. *Review of the SN note dated 2/18 and 2/19/25, showed on comments, left foot lateral open wound cleansed with wound cleanser and pat dry, applied medihoney, abdominal pad, wrap with kerlix, secured with tape. However, further review of the SN notes showed in the goals and interventions performed cleansed with wound cleanser and pat dry, applied collagen powder and gentamicin ointment, apply barrier cream around the peri-wound to help protect site from maceration, cover with gauze and apply dry adhesive dressing. An MD order on 2/24/25, showed a new wound order for the left lateral foot open wound to cleanse with wound cleanser and pat dry, apply collagen particles and gentamicin ointment for prophylaxis, zinc oxide cream to peri-wound, cover with gauze and apply adhesive dry dressing three times a week. *Review of the SN note dated 2/26/25, showed on comments, wound care was done for the lateral left foot open wound. However, further review of the SN notes showed in the goals and interventions, wound care was performed on the left foot 5th toe. The POC, for the certification period from 3/7/25 to 5/5/25, showed SN to perform wound care to the following: -Left lateral foot open wound cleanse with wound cleanser and pat dry apply gentamicin ointment and cover with calcium alginate, zinc oxide cream to peri-wound and cover with gauze and dry adhesive dressing each visit. -Left foot 5th toe, cleanse with wound cleanser and and pat dry apply gentamicin ointment and cover with gauze and adhesive dressing each visit. *Review of the SN note dated 3/9/25, showed on comments, left foot lateral open wound, cleansed with wound cleanser and pat dry, applied gentamicin, calcium alginate, gauze, apply adhesive dressing and on left 5th toe open wound, cleansed with wound cleanser and pat dry, apply gentamicin, calcium alginate, gauze, applied adhesive dressing. However, further review of the SN notes showed in the goals and nterventions, no intervention was performed on the left 5th toe open wound. An MD order on the following dates showed a new wound care order: -On 3/11/25 showed a new wound care order for the following for the left 5th toe cleanse with wound cleanser and pat dry, apply gentamicin and cover with calcium alginate and gauze and apply adhesive dressing each visit. -On 3/18/25 showed a new wound care order for the left 5th toe and left lateral foot to cleanse with NSS, pat dry, apply gentamicin ointment, then calcium alginate, cover with gauze, then cover with bordered gauze. Change dressings daily and as needed for soilage and loss of integrity. *Review of the SN note dated 3/9, 3/12, 3/14, and 3/18/25, showed on comments, left foot lateral open wound, cleansed with wound cleanser and pat dry, applied gentamicin, calcium alginate, gauze, apply adhesive dressing and on left 5th toe open wound, cleansed with wound cleanser and pat dry, apply gentamicin, calcium alginate, gauze, applied adhesive dressing. However, further review of the SN notes showed in the goals and interventions, wound care performed on the left lateral foot open wound cleanse with wound cleanser and pat dry, applied gentamicin ointment and covered with calcium alginate, zinc oxide cream to peri-wound and cover with gauze and dry adhesive dressing each visit and performed wound care to the left foot 5th toe, cleansed with wound cleanser and pat dry applied gentamicin ointment and cover with gauze and adhesive dressing each visit. b.The POC for certification period from 3/7/25 to 5/5/25, showed to report to the physician systolic BP greater than 160. A joint home visit with the RN 2 was conducted on 3/19/25 at 1100 hours, to Patient 2’s home. The RN 2 was observed taking the blood pressure of Patient 2. The BP was at 192/78. RN 2 did not re-take Patient 2’s BP. * However, review of the SN note dated 3/19/25 showed, the BP was at 152/72. RN 1 were informed and acknowledged the findings. #. Review of Patient 18's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/27/25. The patient was certified for home health services during the certification period from 1/27/25 to 3/27/25. The written agreement of Contractor 1 dated 1/1/24, showed the Contractor shall submit clinical notes within 72 hours after completion of the visit. The PT notes from Contractor 1 showed PTs visit were conducted on 3/11, 3/14, 3/18, and 3/21/25. * However, there was no documented evidence the PT submitted the clinical notes within 72 hours after completion of the visit as per the written agreement. On 3/26/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. #. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The POC, for the certification period from 1/30/25 to 3/30/25, cited SN visit 2-3 W8, 1W1, and 3 PRN visits for change in condition. The POC showed the nutritional requirements included regular low sodium and heart healthy; and the clinician to assist the patient to obtain ERS button. a. The SN notes dated 2/1, 2/3, 2/5, 2/7, 2/8, 2/10, 2/11, 2/14, 2/17, 2/19, 2/20, 2/21, 2/24, 2/26, 2/28, 3/3, 3/5, 3/7, and 3/12/25, showed the patient’s diet was regular instead of regular low sodium and heart healthy which was not consistent as per the POC. b. The SN notes dated 2/1/25, showed under Interventions Performed related in assisting the patient to obtain ERS button included the intervention was performed on the patient and verbalized understanding. * However, there was no documented evidence on what was the status in obtaining the ERS button. c. The PT Evaluation dated 2/3/25, showed the patient had 10/10 right knee pain (0=no pain 10=worst pain). Documentation showed the pain was increased by movement and activity and relieved by rest. Documentation showed the pain interfered with ADLs and the physician was aware. * However, there was no documented evidence on what the physician’s response on the patient’s 10/10 pain was. The PT Re-Evaluation dated 3/7/25, showed the patient had 9/10 low back pain. Documentation showed the pain was increased by movement and activity and relieved by rest and medications. Documentation showed the pain interfered with ADLs and the physician was aware. * However, there was no documented evidence on what the physician’s response on the patient’s 9/10 pain was. d. The SN note on Week 7 (3/9/25 to 3/15/25), showed the SN conducted a visit on 3/12/25. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She stated the SN conducted another SN visit on 3/14/25. However, the SN note dated 3/14/25 was not available in the electronic record system. On 3/26/25 at 1200 hours, the Administrator was informed and acknowledged the findings. #. Review of Patient 10's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 2/7/25. The patient was certified for home health services during the certification periods from 2/7/25 to 4/7/25. The POC, during the certification period from 2/7/25 to 4/7/25, cited SN visits 1W1, 2W3, 1W5 plus 2 PRN with change in condition. The POC showed the clinician to assist the patient to obtain ERS button. The SN note dated 2/20/25, showed the intervention was completed related to the clinician assisting the patient to obtain ERS button. * However, there was no documented evidence if the patient was able to obtain the ERS button. On 3/26/25 at 1317 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. Review of the agency’s P&P titled Contents of the Clinical Record revised 11/2021 showed the clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. Signed and dated progress notes for each discipline rending service. Clinical notes shall be signed and incorporated into the patient’s health record at least every seven working days. 1. Review of Patient 1’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 9/30/24. The patient was certified for home health services during the certification period from 1/28/25 to 3/28/25. The POC, for the certification period from 1/28/25 to 3/29/25, cited PT visits for 1-2w8. Review of Patient 1’s PT notes showed, “not started” on 3/4, 3/6, and 3/11/25. On 3/18/25 at 1415 hours, an interview and concurrent clinical record review was conducted with the Administrator. When asked, the Administrator verified the PT notes were entered by the assigned PT on 3/18/25 at 1328 hours. The Administrator showed the submission audit log for each PT notes which showed the above PT notes were entered more than seven working days of when the service was rendered. The Administrator was informed and acknowledged the above finding. 2. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification periods from 2/1/25 to 4/1/25. The POC, for the certification period from 2/1/25 to 4/1/25, showed to notify the physician if the systolic BP greater than 160 mmHg or less than 90 mmHg and if the diastolic BP greater than 90 mmHg or less than 50 mmHg. Review of the SN notes dated 3/14/25, showed the systolic BP of 123 mmHg. However, the diastolic BP section was left blank. On 3/26/25 at 1034 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding. 3. Review of Patient 18's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/27/25. The patient was certified for home health services during the certification period from 1/27/25 to 3/27/25. The written agreement of Contractor 2 dated 1/1/24, showed the Contractor shall submit the clinical notes within 72 hours after completion of the visit. The PT notes from Contractor 2 showed the PT visits were conducted on 3/11, 3/14, 3/18, and 3/21/25. * However, there was no documented evidence the PT submitted the clinical notes within 72 hours after completion of the visit as per the written agreement. On 3/26/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 4. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The POC, for the certification period from 1/30/25 to 3/30/25, cited SN visit 2-3 W8, 1W1, and 3 PRN visits for change in condition. The POC showed the nutritional requirements included regular low sodium and heart healthy; and the clinician to assist the patient to obtain ERS button. a. The SN notes dated 2/1, 2/3, 2/5, 2/7, 2/8, 2/10, 2/11, 2/14, 2/17, 2/19, 2/20, 2/21, 2/24, 2/26, 2/28, 3/3, 3/5, 3/7, and 3/12/25, showed the patient’s diet was a regular diet instead of regular low sodium and heart healthy diet which was not consistent with the POC. b. The SN notes dated 2/1/25, showed the Interventions Performed related in assisting the patient to obtain ERS button included the intervention was performed on the patient and verbalized understanding. * However, there was no documented evidence on what the status was for obtaining the ERS button. c. The PT Evaluation dated 2/3/25, showed the patient had the right knee pain with the pain level of 10 (on a 0-10 pain scale, 0=no pain 10=worst pain). Documentation showed the pain was increased by movement and activity and relieved by rest. Documentation showed the pain interfered with ADL care and the physician was aware. * However, there was no documented evidence of the physician’s response regarding the patient’s pain level of 10. The PT Re-Evaluation dated 3/7/25, showed the patient had a pain level of 9 for the low back pain. Documentation showed the pain was increased by movement and activity and relieved by rest and medications. Documentation showed the pain interfered with ADL care and the physician was aware. * However, there was no documented evidence of the physician’s response regarding the patient’s pain level of 9. d. The SN note during Week 7 (3/9/25 to 3/15/25), showed the SN conducted a visit on 3/12/25. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She stated the SN conducted another SN visit on 3/14/25. However, the SN note dated 3/14/25, was not available in the electronic record system. On 3/26/25 at 1200 hours, the Administrator was informed and acknowledged the findings. 5. Review of Patient 10's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 2/7/25. The patient was certified for home health services during the certification period from 2/7/25 to 4/7/25. The POC, during the certification period from 2/7/25 to 4/7/25, cited SN visits 1W1, 2W3, 1W5 and 2 PRN visits with change in condition. The POC showed the clinician to assist the patient to obtain ERS button. The SN note dated 2/20/25, showed the intervention was completed related to assisting the patient to obtain ERS button. * However, there was no documented evidence if the patient was able to obtain the ERS button. On 3/26/25 at 1317 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 6. Review of Patient 2’s clinical record showed SOC was 7/10/24. The clinical record showed the patient received home health services during the certification periods from 1/6/25 to 3/6/25 and 3/7/25 to 5/6/25. a. The POC, for the certification period from 1/6/25 to 3/6/25, cited SN to perform wound care to the left lateral foot open wound as follows: to cleanse with wound cleanser, pat dry, and apply santyl and gauze at each visit. The physician's order on 2/18/25, showed a new wound care order for the left lateral foot as follows: to cleanse with wound cleanser and pat dry, apply collagen powder and gentamicin ointment, apply barrier cream around the peri-wound to help protect site from maceration, cover with gauze, and apply a dry adhesive dressing. *Review of the SN notes dated 2/18 and 2/19/25, showed the left foot lateral open wound was cleansed with wound cleanser and pat dry, applied medihoney and abdominal pad, wrap with kerlix, secured with tape. However, further review of the SN notes showed in the goals and interventions section, the SN cleansed the wound with wound cleanser, patted dry, applied collagen powder and gentamicin ointment, applied barrier cream around the peri-wound to help protect site from maceration, covered with a gauze, and apply a dry adhesive dressing. The physician's order dated 2/24/25, showed a new wound order for the left lateral foot open wound as follows: to cleanse with wound cleanser, pat dry, apply collagen particles and gentamicin ointment for prophylaxis, zinc oxide cream to peri-wound, cover with a gauze and apply adhesive dry dressing three times a week. *Review of the SN note dated 2/26/25, showed wound care was done for the lateral left foot open wound. However, the goals and interventions section showed wound care was performed on the left foot 5th toe. b. The POC, for the certification period from 3/7/25 to 5/5/25, cited SN to perform wound care as follows: -Left lateral foot open wound, to cleanse with wound cleanser, pat dry, apply gentamicin ointment, cover with calcium alginate, zinc oxide cream to peri-wound, and cover with the gauze and dry adhesive dressing each visit. -Left foot 5th toe, to cleanse with wound cleanser, pat dry, apply gentamicin ointment, and cover with the gauze and adhesive dressing each visit. *Review of the SN note dated 3/9/25, showed for the left foot lateral open wound, the SN cleansed with wound cleanser, patted dry, and applied gentamicin, calcium alginate, gauze, and adhesive dressing; and for the left 5th toe open wound, the SN cleansed with wound cleanser, patted dry, and applied gentamicin, calcium alginate, gauze, and adhesive dressing. However, further review of the SN notes showed under the goals and nterventions sections, no intervention was performed for the left 5th toe open wound. c. Review of the physician's orders showed the following wound care orders: -On 3/11/25, a new wound care order for the left 5th toe as follows: to cleanse with wound cleanser, pat dry, apply gentamicin, cover with calcium alginate and gauze, and apply an adhesive dressing each visit. -On 3/18/25, a new wound care order for the left 5th toe and left lateral foot as follows: to cleanse with NSS, pat dry, apply gentamicin ointment, then calcium alginate, cover with a gauze and bordered gauze; and to change dressings daily and as needed for soilage and loss of integrity. *Review of the SN notes dated 3/9, 3/12, 3/14, and 3/18/25, showed the comments section showing the following wound care performed: -For the left foot lateral open wound, the cleansed the wound with wound cleanser, patted dry, applied gentamicin, calcium alginate, gauze, and adhesive dressing; and for the left 5th toe open wound, the SN cleansed the wound with wound cleanser, patted dry, and applied gentamicin, calcium alginate, gauze, and adhesive dressing. However, the goals and interventions section showed the following wound care performed: -For the left lateral foot open wound, the SN cleansed the wound with wound cleanser, patted dry, applied gentamicin ointment, covered with calcium alginate, applied zinc oxide cream to peri-wound, and covered with the gauze and dry adhesive dressing each visit; and for the left foot 5th toe, the SN cleansed the wound with wound cleanser, patted dry, applied gentamicin ointment, and covered with the gauze and adhesive dressing each visit. d. The POC, for certification period from 3/7/25 to 5/5/25, showed to report to the physician for systolic BP greater than 160 mmHg. A joint home visit with RN 2 was conducted on 3/19/25 at 1100 hours, to Patient 2’s home. RN 2 was observed taking the patient's blood pressure. The BP was at 192/78 mmHg. However, review of the SN note dated 3/19/25, showed the patient's BP was 152/72 mmHg. RN 1 were informed and acknowledged the findings. 7. Review of Patient 6's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 9/7/22. The patient was certified for home health services during the certification periods from 12/25/24 to 2/22/25 and 2/23/25 to 4/23/25. The primary diagnosis was encounter for attention to ileostomy. a. Review of the Case Conferences dated 1/21 and 2/18/25, showed the patient continued to require SN visits for colostomy care and maintenance. However, the patient diagnosis was for attention to ileostomy instead of colostomy. b. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 2 to 3W8, 1 to 2 W1 and 3 PRN visits for conditions/complications. Review of the SN notes dated 12/25, 12/27, 12/30, 1/2, 1/4, 1/6, 1/13, 1/15, 1/17, 1/20, 1/22, 1/24, 1/27, 1/29, 1/31, 2/3, 2/5, 2/7, 2/10, 2/12, 2/14, 2/17, 2/19, and 2/21/25, showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with the patient's activity or movement = patient has no pain or does not interfere with activity, - the primary site = fingers, - pain intensity = 3, - current pain management and effectiveness = does not take pain medication - what makes the pain worse = ADL's. However, the section of the frequency of pain interfering with the patient's activity or movement showed the patient has no pain which was inconsistent. c. The POC, for the certification period from 2/23/25 to 4/23/25, cited SN visits 2 to 3 W9 and 3 PRN visits for conditions/complications. Review of the SN notes dated 2/24, 2/26, 2/28, 3/1, and 3/3/25, showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with the patient's activity or movement = patient has no pain or does not interfere with activity, - the primary site = fingers, - pain intensity = 3, - current pain management and effectiveness = does not take pain medication - what makes the pain worse = ADL care. In addition, review of the SN visit notes dated 3/5, 3/7, 3/10, 3/12, and 3/14/25, showed the patients pain intensity was 4. However, the section of the frequency of pain interfering with the patient's activity or movement showed the patient had no pain which was inconsistent. d. Review of the SN visit calendar for the certification periods from 2/23/25 to 4/23/25, showed the assigned SN, target date, visit date, status, and miscellaneous. The SN visit dates from 3/5, 3/7, 3/10/25 , 3/12, 3/14 and 3/17/25, showed the status was not started, colored red. On 3/30/25 at 1300 hours, the Administrator was asked to provide the audit trail for the SN visit notes starting from 3/5/25. The Administrator provided the task audit for the charts. Review of the Task Details dated 3/5, 3/7, 3/10, 3/12, and 3/14/25, showed the SN submitted the visit notes on 3/20/25. On 3/26/25 at 1526 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if there was an SN missed visits during Weeks 3 and 4. The Clinical Manager stated there was a visit but the SN submitted the notes late. The Clinical Manager was informed and acknowledged the findings. 8. Review of Patient 17's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification period from 9/28/24 to 11/26/24. The patient's primary diagnosis was acute and chronic respiratory failure with hypoxia. The other diagnoses included chronic systolic (congestive ) heart failure. The POC, for the certification period from 9/28/24 to 11/26/24, cited SN visits once every other week x6, 1W1 starting 11/10/24, and 3 PRN visits for change in condition. *Review of the SN visit notes dated 10/10, 10/23 and 11/12/24/24, showed the SN had performed an assessment which included the patients weight. However, the SN documented the patient's weight as "same." On 3/26/24 at 1008 hours an interview and concurrent clinical record review was conducted with the Clinical Manager. When asked, the Clinical Manager reviewed the clinical record and stated it should be specific. The Clinical Manager was informed and acknowledged the findings. 9. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. a. The POC for the certification periods 11/21/24 to 1/19/25, cited SN visits 1W9 and 2 PRN visits for patient assessment. Review of the SN visit note dated 12/31/24, showed the SN had performed an assessment and wound treatment to the coccyx. The note showed to perform/instruct caregiver to clean affected area of coccyx with wound cleanser or soap and water, dry well, apply skin prep to area, cover with a thin hydrocolloid dressing, and secure with transparent film. However, review of the clinical record showed a check marked on WNL on the section of skin assessment which was inaccurate. In addition, review of the SN notes dated 11/25, 12/2, 12/19, 12/31/24, and 1/8/25, showed the SN had provided G-tube care. However, the SN documented the patient's skin as WNL which was inaccurate. On 3/26/25 at 1155 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed of the findings. b. The POC, for the certification period from 1/20/25 to 3/20/25, cited SN and PT services. Review of the Patient communication dated 1/23/24, showed the OT evaluation was not completed. However, there was no order for OT. On 3/26/25 at 1121 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. When asked, the Clinical Manager reviewed the clinical record and stated did not see an order and it was a charting error. The Clinical Manager was informed and acknowledged the findings. 10. Review of Patient 12's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 1/24/25. The patient was certified for home health services during the certification period from 1/24/25 to 3/24/25. The POC, for the certification period from 1/24/25 to 3/24/25, cited SN visits 1W1, 1 to 2W1, 1W4, and 3 PRN visits. The POC showed the primary diagnosis was encounter for other orthopedic aftercare. The interventions included SN to assess pain level and effectiveness of pain medications and current pain management every visit. Review of the SN notes dated 1/28/25, showed the SN had performed pain assessment. The pain assessment included the following: - frequency of pain interfering with the patient's activity or movement = daily but not constantly, - the primary site = posterior neck, - pain intensity = 7, - current pain management and effectiveness = medication, rest - what makes the pain worse = movement. However, review of the SN notes dated 1/312/3, 2/11, 2/18, 3/25, and 3/4/25 failed to show the SN had performed completed pain assessment as the section for "what makes the pain worse" was left blank. On 3/26/25 at 1058 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the findings. 11. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. a. The POC, for the certification period from 12/12/24 to 2/9/25, cited SN visits 1W8 and 2 PRN visits for change of condition. The SN visit note dated 1/25 and 2/7/25, showed the SN documented a lesion on the patient's right upper lateral arm, measuring 2.4 cm x 3.9 cm with scant amount of serosanguinous drainage, no odor. The SN provided wound care as follows: cleansed lesion with wound care cleanser, patted dry, applied antibacterial ointment, and covered with a 4x4 non-adherent bordered gauze dressing. However, the section of skin assessment showed the SN marked the skin as WNL which was inconsistent. b. The POC, for the certification period from 2/10/25 to 4/10/25, cited SN visits 1W9 and 2 PRN visits for change of condition. Review of the SN visit note dated 2/13 and 3/3/25, showed the open wounds to the patients right lateral arm. The documentation showed an open wound 1, 2 and 3 located at the right lateral arm. The Wound 3 was assessed as to the status of wound, measurement, color, drainage, odor and surrounding tissue. However, on the section for the skin assessment showed the SN marked the skin as WNL which was inconsistent. On 1336 hours, an interview and concurrent clinical record review was conducted with the Clinical Director. The Clinical Director was informed of the findings.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of 18 sampled patients (Patient 14). This failure had the potential for substandard health outcomes to this patient. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. Review of the clinical record for Patient 14 showed the LVN did not provide services in accordance with the POC for this patient. Cross reference to G710, example #2. The SN note dated 2/19 and 3/5/25, showed the RN had conducted a supervisory visit and the LVN satisfactorily followed the plan of care. * However, the RN failed to identify the LVN did not provide services in accordance with the POC. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written patient care instructions for the CHHA were developed by the RN for one of eight sampled patients (Patient 14). This failure had the potential for not addressing the care needs for this patient. Findings: Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The Aide Care Plan for the certification period dated 1/30/25 to 3/30/25, showed CHHA visits 2W8. The care plan included tasks to be performed by the CHHA. The CHHA notes showed the patient's BP, pulse, respiration, and temperature were obtained by the CHHA during the visits. However, the Aide Care Plan did not include this task for CHHA to perform during the visits. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She stated the Aide Care Plan should include the CHHA to obtain BP, pulse, respiration, and temperature during the visits. She was informed and acknowledged the finding.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the CHHA services were provided in accordance with the care plans for two of 18 sampled patients (Patient 9 and 14). This failure had the potential for not providing the appropriate, consistent, and quality care to these patients. 1. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The physician's order dated 2/5/25, showed CHHA visits 2W8 as requested by the patient. * However, there was no documented evidence the CHHA had conducted two visits during Week 2 (2/2/25 to 2/8/25) as per the physician’s order dated 2/5/25. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 2. Review of Patient 9's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 8/3/24. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The POC, during the certification period from 1/30/25 to 3/30/25, cited CHHA visits 1-2 W9. The Aide Care Plan for the certification period dated 1/30/25 to 3/30/25, showed CHHA to notify if the patient had no bowel movement in three days. The CHHA note dated 3/6/25, showed the patient’s last BM was 3/2/25. * However, there was no documented evidence the CHHA notified the RN of the patient’s last BM more than three days. On 3/26/25 at 1300 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency's RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for two of 18 sampled patients (Patients 9 and 14). This failure had the potential for substandard health outcomes to this patient. Findings: 1. Review of Patient 14's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 1/30/25. The patient was certified for home health services during the certification period from 1/30/25 to 3/30/25. The physician's order dated 2/5/25, showed CHHA visits 2W8 as requested by the patient. The CHHA notes showed the CHHA visits were conducted during Week 3 (2/9/25 to 2/15/25), Week 4 (2/16/25 to 2/22/25), Week 5 (2/25/25 to 3/1/25), and Week 6 (3/2/25 to 3/8/25). * However, there was no documented evidence the RN completed a supervisory visit to conduct the assessment of CHHA services provided no less frequently than every 14 days during the above time period. On 3/26/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 2. Review of Patient 9's clinical record was initiated on 3/20/25. The clinical record showed the SOC was 8/3/24. The patient was certified for home health services during the certification periods from 1/30/25 to 3/30/25. The POC, for the certification period from 1/13/25 to 3/13/25, cited CHHA visits 1-2 W9. The CHHA notes showed the CHHA visits were conducted on Week 5 (2/23/25 to 3/1/25), Week 6 (3/2/25 to 3/8/25), and Week 7 (3/8/25 to 3/15/25). The SN note date 2/24/25, showed the RN completed a supervisory assessment of the CHHA services. *However, there was no documented evidence the RN completed a supervisory visit to assess the CHHA services 14 days after the last supervisory visit on 2/24/25. On 3/26/25 at 1300 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding.

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 the agency's P&Ps were implemented as evidenced by: The annual performance evaluation and skilled competency were not completed for CHHAs 1 and 2. The TB screening was not updated for CHHA 2.The wound assessments were not performed for Patients 4, 5, 10, and 13.The grievance resolution was not sent for Patients A, B, and C. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: #. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification periods from 2/1/25 to 4/1/25. The POC, for the certification period from 2/1/25 to 4/1/25, showed Patient 4 had a right ankle open wound. Cited SN visits for 1-2w9 (one to two visits a week for nine weeks) and 2 prn beginning 2/2/25. The SN interventions showed SN to assess/evaluate wound(s) at each dressing change and prn for signs/symptoms of infection. In addition, the SN to perform/instruct the patient/caregiver on wound care as follows: right outer ankle trauma wound; cleanse with wound cleanser, apply Medihoney to wound bed, skin prep edges, cover with foam dressing, gauze wrap, tape, Coban two times a week and prn; patient/caregiver to perform wound care on non-SN visit days. Review of SN visit notes dated 2/4, 2/6, 2/14, 2/17, and 2/21/25, showed RN 3 performed an intervention of wound care dressing change to Patient 4’s right outer ankle wound. However, the SN visit notes failed to show documented evidence RN 3 had assessed or evaluated Patient 4’s right outer ankle wound as per the agency’s P&P. On 3/26/25 at 1032 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 stated the nurse should have documentation of the size, location, characteristics, and signs/symptoms of infection of the wound. RN 1 verified there was no documentation of the nurse’s assessment or evaluation of Patient 4’s right ankle open wound with the SN notes dated listed above and acknowledged the above finding. #. Review of the agency’s P&P titled Categories/Qualifications of Personnel revised 11/2021 showed the organization defines the qualifications, competencies, health status, and type of staffing needed to fulfill its mission. For professional personnel, must demonstrate their competency, within their orientation and probationary period, according to the orientation checklists developed for each position. In addition, ongoing competency assessments will be performed through joint visits, based on the degree and complexity of care being performed and by monitoring information regarding performance. For Home Health Aide, must demonstrate their competency, within orientation, according to the orientation checklist and activities delineated in the CMS competency testing. In addition, ongoing competency assessments are performed through observation and supervisory visits every two weeks as well as monitoring information regarding performance. The ongoing competency review is part of the annual performance evaluation. Provide for a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter using a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and g Administration (FDA). Review of the personnel file was conducted on 3/25/25 for the following staff: -CHHA 1’s personnel file showed the hiring date was 6/1/21. * However, there was no documented evidence of the annual performance evaluation and skills competency were completed. -CHHA 2’s personnel file showed the hiring dated was 5/23/18. * However, there was no documented evidence of the annual performance evaluation and skills competency were completed. In addition, CHHA 2’s TB screening was not updated. Furthermore, there was no documentation the skills competency check was updated for the following personnel: -RN 2, showed the hiring date was 10/25/18; -RN 3, showed the hiring date was 6/26/19; -RN 4, showed the hiring date was 2/27/12; -RN 5, showed the hiring date was 11/28/22; -LVN 1, showed the hiring date was 10/3/24; and -LVN 2, showed the hiring date was 10/3/22. On 3/26/25 at 1330 hours, an interview and concurrent document review was conducted with the HR staff. The HR staff was informed and acknowledged of the finding. #. The agency P&P titled Complaint/Grievance Process revised 11/2021, showed the purpose was to set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. The procedure includes response to the patient regarding the complaint will occur within 10 days of receipt and the resolution information will be communicated in writing to the patient or his/her representative filing the complaint. Review of the agency’s grievance log was conducted on 3/25/25. The grievance log included the complaints from 2022 to 2025. The grievance log showed on the following year: -On 2024, the agency had documented a total of four complaints with investigation reports. An example of the complaints showed the agency received a complaint from Patient A dated 10/14/24. The complaint was investigated by the Administrator. The date of the resolution was on 11/4/24. However, review of the log failed to show documented evidenced of the resolution response was sent to the patient or representative as per P&P. -On 2023, the agency had documented a total of three complaints with investigation reports. An example of the complaints showed the agency received a complaint from Patient B dated 7/26/23. The complaint was investigated by the Administrator. The date of the resolution was on 7/26/23. However, review of the log failed to show documented evidenced of the resolution response was sent to the patient or representative as per P&P. -On 2022, the agency had documented a total of nine complaints with investigation reports. An example of the complaints showed the agency received a complaint from Patient C dated 12/22/22. The complaint was investigated by the Administrator. The date of the resolution was on 12/23/22. However, review of the grievance/complaint reports failed to show documented evidenced of the resolution response was sent to the patient or representative as per P&P. On 3/30/25 at 1422 hours, an interview and concurrent document review was conducted with the Clinical Manager. The Clinical Manager was asked if a resolution letter was sent to the complainant or their representative. The Clinical Manger replied no documentation of the resolution letter was sent. The Clinical Manager was informed and acknowledged the findings. #. The agency P&P titled Wound Care Procedure revised 11/2021 showed, to ensure optimal healing of wounds and to type of wound in order to provide proper wound care. The policy included wounds are to be measured weekly, re-evaluate wounds with changes in condition and report to the physician wound status and to submit a communication note to the agency on the same day. The procedure includes the description of wound and surrounding area including drainage, slough, color, odor, bone/muscle exposure, eschar, or any other observations to clearly describe the wound. *Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The POC for the certification periods 11/21/24 to 1/19/25 cited SN visits 1W9 plus 2 PRN for patient assessment. Review of SN visit note dated 12/31/24, showed the SN had performed an assessment. The interventions performed included a wound treatment to the coccyx. The SN to perform/instruct caregiver to clean affected area of coccyx with wound cleanser or soap and water, dry well, apply skin prep to area cover with thin hydrocolloid dressing and secure with transparent film. However, review of the clinical record failed to show documented evidenced of the a wound assessment was performed as per P&P. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if there was a wound assessment . The Clinical Manager reviewed the clinical record and replied, no wound assessment. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. The POC for the certification period from 2/10/25 to 4/10/25 cited SN visits 1W9 (one time a week for nine weeks) plus 2 PRN for change of condition. Review of the SN visit note dated 2/13 and 3/3/25, showed the SN had documented an open wound to the patients right lateral arm. The documentation showed an open wound 1, 2 and 3 located at the right lateral arm. The Wound 3 was assessed as to the status of wound, measurement, color, drainage, odor and surrounding tissue. However, review of the clinical record failed to show documented evidenced of the wound assessment was completed for Wound 1 and 2. On 1307 hours, an interview and concurrent clinical record review was conducted with the Clinical Director. The Clinical Director was asked if there was an assessment for Wounds 1 and 2. The Clinical Manager reviewed the clinical record and replied, don't see the wound assessment were completed. The Clinical Manager was also asked as to the frequency of the wound assessment. The Clinical Manager replied, every SN visit. The Clinical Manager was informed and acknowledged the findings. #. Review of Patient 10's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 2/7/25. The patient was certified for home health services during the certification periods from 2/7/25 to 4/7/25. The POC, during the certification period from 2/7/25 to 4/7/25, cited SN visits 1W1, 2W3, 1W5 plus 2 PRN with change in condition. The POC showed SN to perform/instruct patient/caregiver on wound care as follows: cleanse right dorsal foot with wound cleanser or NS, cover with “Polymen/foam silver dressing” (wound dressing), wrap with gauze and tape two times a week and PRN with soiling until healed. * There was no documented evidence of the patient's right dorsal foot wound measurement during Week 2 (2/9/25 to 2/25/25), which was not consistent with the wound care P&P. On 3/26/25 at 1317 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding. 1. Review of the agency’s P&P titled Categories/Qualifications of Personnel revised 11/2021 showed the organization defines the qualifications, competencies, health status, and type of staffing needed to fulfill its mission. For Home Health Aide, individuals must demonstrate their competency, within orientation, according to the orientation checklist and activities delineated in the CMS competency testing. In addition, ongoing competency assessments are performed through observation and supervisory visits every two weeks as well as monitoring information regarding performance. The ongoing competency review is part of the annual performance evaluation. The P&P showed to provide for a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter using a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and g Administration (FDA). Review of the personnel files was conducted on 3/25/25, showed the following: -CHHA 1’s personnel file showed the hiring date was 6/1/21. * However, there was no documented evidence of the annual performance evaluation and skills competency were completed. -CHHA 2’s personnel file showed the hiring dated was 5/23/18. * However, there was no documented evidence of the annual performance evaluation and skills competency were completed. In addition, CHHA 2’s TB screening was not updated. On 3/26/25 at 1330 hours, an interview and concurrent document review was conducted with the HR staff. The HR staff was informed and acknowledged of the finding. 2. The agency's P&P titled Complaint/Grievance Process revised 11/2021 showed the purpose is to set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. The procedure includes response to the patient regarding the complaint will occur within 10 days of receipt and the resolution information will be communicated in writing to the patient or his/her representative filing the complaint. Review of the agency’s grievance log was conducted on 3/25/25. The grievance log included the complaints from 2022 to 2025 and showed the following: - In 2024, the agency had a total of four complaints with investigation reports. For example, the agency received a complaint from Patient A dated 10/14/24. The complaint was investigated by the Administrator. The date of the resolution was on 11/4/24. However, review of the log failed to show documented evidence of the resolution response sent to the patient or representative as per the agency's P&P. - In 2023, the agency had a total of three complaints with investigation reports. For example, the agency received a complaint from Patient B dated 7/26/23. The complaint was investigated by the Administrator. The date of the resolution was on 7/26/23. However, review of the log failed to show documented evidence of the resolution response sent to the patient or representative as per the agency's P&P. - In 2022, the agency had a total of nine complaints with investigation reports. For example, the agency received a complaint from Patient C dated 12/22/22. The complaint was investigated by the Administrator. The date of the resolution was on 12/23/22. However, review of the grievance/complaint reports failed to show documented evidence of the resolution response sent to the patient or representative as per the agency's P&P. On 3/26/25 at 1422 hours, an interview and concurrent document review was conducted with the Clinical Manager. The Clinical Manager was asked if a resolution letter was sent to the complainant or their representative. The Clinical Manger sated no documentation of the resolution letter was sent. The Clinical Manager was informed and acknowledged the findings. 3. The agency's P&P titled Wound Care Procedure revised 11/2021 showed to ensure optimal healing of wounds and type of wound in order to provide proper wound care. The policy included wounds are to be measured weekly, re-evaluate wounds with changes in condition and report to the physician wound status and to submit a communication note to the agency on the same day. The procedure included the description of wound and surrounding area including drainage, slough, color, odor, bone/muscle exposure, eschar, or any other observations to clearly describe the wound. a. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The POC for the certification period from 11/21/24 to 1/19/25, cited SN visits 1W9 plus 2 PRN visits for patient assessment. Review of the SN visit note dated 12/31/24, showed the SN had performed a wound treatment to the patient's coccyx. However, there was no documented evidenced of the wound assessments as per the agency's P&P. On 3/26/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was asked if there was a wound assessment . The Clinical Manager reviewed the clinical record and replied, no wound assessment. The Clinical Manager was informed and acknowledged the findings. b. Review of Patient 5's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 12/12/23. The patient was certified for home health services during the certification periods from 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25. The POC, for the certification period from 2/10/25 to 4/10/25, cited SN visits 1W9 (one time a week for nine weeks) and 2 PRN visits for change of condition. Review of the SN visit note dated 2/13 and 3/3/25, showed the the patient had three open wounds on the right lateral arm, Wounds 1, 2, and 3. The note showed the status of wound, measurement, color, drainage, odor and surrounding tissue for Wound 3. However, there was no documented evidence of the wound assessments for Wounds 1 and 2. On 3/26/25 at 1307 hours, an interview and concurrent clinical record review was conducted with the Clinical Director. When asked, the Clinical Manager reviewed the clinical record and stated no wound assessments were completed. The Clinical Manager was also asked regarding the frequency of the wound assessment. The Clinical Manager stated every SN visit. The Clinical Manager was informed and acknowledged the findings. c. Review of Patient 4’s clinical record was initiated on 3/19/25. The clinical record showed the SOC was 8/11/23. The patient was certified for home health services during the certification period from 2/1/25 to 4/1/25. The POC, for the certification period from 2/1/25 to 4/1/25, showed Patient 4 had the right ankle open wound. The POC cited SN visits for 1-2w9 (one to two visits a week for nine weeks) and 2 PRN visits beginning 2/2/25. The SN interventions showed SN to assess/evaluate wound(s) at each dressing change and PRN for signs/symptoms of infection. In addition, the SN was to perform/instruct the patient/caregiver on wound care as follows: for the right outer ankle trauma wound; cleanse with wound cleanser, apply Medihoney to wound bed, skin prep edges, cover with foam dressing, gauze wrap, tape, Coban two times a week and prn; patient/caregiver to perform wound care on non-SN visit days. Review of the SN visit notes dated 2/4, 2/6, 2/14, 2/17, and 2/21/25, showed RN 3 performed wound care dressing change to Patient 4’s right outer ankle wound. However, there was no documented evidence RN 3 had assessed or evaluated Patient 4’s right outer ankle wound as per the agency’s P&P. On 3/26/25 at 1032 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 stated the nurse should have documentation of the size, location, characteristics, and signs/symptoms of infection of the wound. RN 1 verified and acknowledged the above finding. d. Review of Patient 10's clinical record was initiated on 3/24/25. The clinical record showed the SOC was 2/7/25. The patient was certified for home health services during the certification periods from 2/7/25 to 4/7/25. The POC, during the certification period from 2/7/25 to 4/7/25, cited SN visits 1W1, 2W3, 1W5 and 2 PRN visits with change in condition. The POC showed SN to perform/instruct patient/caregiver on wound care as follows: cleanse the right dorsal foot with wound cleanser or NS, cover with “Polymen/foam silver dressing” (wound dressing), wrap with a gauze and tape two times a week and PRN with soiling until healed. * There was no documented evidence of the patient's right dorsal foot wound measurements during Week 2 (2/9/25 to 2/25/25). On 3/26/25 at 1317 hours, an interview and concurrent clinical record review was conducted with the Administrator. She was informed and acknowledged the finding.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's CHHA prepared the accurate visit notes to reflect the interventions provided as per the plan of care for one of 18 sampled patients (Patient 3). This failure had the potential for substandard healthcare outcomes for this patient. Findings: Review of Patient 3’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/27/24. The patient was certified for home health services during the certification period from 1/26/25 to 3/26/25. The Aide Care Plan for certification period dated 1/26/25 to 3/26/25, showed CHHA visit 2w9. the Aide Care Plan showed to shampoo the patient’s hair for each visit and use a walker for assist in ambulation. However, the CCHA noted dated 2/20/25, showed the CHHA had conducted a visit. Documentation showed a task for a shampoo hair for each visit and on Saturdays only. In addition, the documentation showed a wheelchair was used for assist in ambulation. On 3/26/25 at 1042 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the completed discharge summaries were sent to the primary care practitioner within five business days of the discharge date for two of 18 sampled discharged patients (Patients 16 and 17 ). In addition, the agency failed to ensure the transfer summary was sent to the physician within two business days for one of 18 sampled patients (Patient 13). These failures had the potential for not providing the necessary care and services to these patients after discharge from the HHA. Findings: #. Review of Patient 16’s closed clinical record was initiated on 3/25/25. The clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. The patient was discharge from the agency on 10/21/25. Review of the physician’s post hospital orders dated 8/28/25, showed patient went to the acute hospital from 8/23/25 to 8/26/25 and the home health services were resumed on 8/28/25. Further clinical record review showed an OASIS E1- Transfer was completed on 8/23/25 with a discharge summary included. However, there was no documented evidence the discharge summary was sent or faxed to the physician. On 3/26/25 at 1301 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 verified the nurse did not send the copy of the OASIS E1- Transfer with the discharge summary to the physician. RN 1 further stated the discharge summary should be send to the physician within two working days. RN 1 acknowledged the above finding. #. Review of Patient 17's clinical record was initiated on 3/21/25. The clinical record showed the SOC was 6/6/23. The patient was certified for home health services during the certification periods from 9/28/24 to 11/26/24. The patient was discharged from HHA on 11/25/24. Review of the OASIS E-Discharge dated 11/25/24 included a section for discharge summary. Review of the clinical record showed the discharge summary was faxed to the physician on 1/10/25 which was more than five business days from the discharge date. On 3/26/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the finding. #. Review of Patient 13's clinical record was initiated on 3/18/25. The clinical record showed the SOC was 11/21/24. The patient was certified for home health services during the certification periods from 11/21/24 to 1/19/25 and 1/20/25 to 3/20/25. The patient was transferred/discharged to inpatient facility on 1/23/25. Review of the clinical record showed an OASIS E1-Transfer was completed on 1/23/25. Review of the clinical record showed the transfer summary was faxed to the physician on 1/29/25 which was more than two days from the unplanned transfer. On 3/26/25 at 1121 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager was informed and acknowledged the finding.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical records were complete and authenticated for two of 18 sampled patients (Patients 1 and 16). This failure had the potential for substandard care provided to these patients as their clinical information was not complete. Findings: 1. Review of the agency’s P&P titled Clinical/Service Data Collection revised 4/2021 showed the signature authorization of the clinical/service documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Review of Patient 16’s closed clinical record was initiated on 3/25/25. The clinical record showed the SOC was 7/15/24. The patient was certified for home health services during the certification periods from 7/15/24 to 9/12/24 and 9/13/24 and 11/11/24. Review of Patient 16’s OT Evaluation Notes dated 9/3/25, showed the recommendations of OT services with a visit frequency of 2w2 (two visits per week for two weeks). The OT evaluation notes showed OT 1 had completed an assessment and had a signature authentication with her name; however, OT 1’s name did not include her professional license credential. Further review of Patient 1’s OT Notes dated 9/4, 9/9, and 9/11/24, showed OT 1 had conducted the OT visits and provided OT services. However, the OT notes showed a signature authentication with OT 1’s name but did not include her professional license credential. On 3/18/25 at 1501 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledge the above finding. 2. Review of Patient 1’s clinical record was initiated on 3/18/25. The clinical record showed the SOC was 9/30/24. The patient was certified for home health services during the certification periods from 1/28/25 to 3/28/25. The POC, for the certification period from 1/28/25 to 3/29/25, cited OT visits 1w1 and 1-2w3. Review of Patient 1’s OT notes dated 1/29, 2/3, 2/6, 2/10, 2/12, 2/17, 2/21, 2/24, 2/26, and 3/2/25, showed OT 1 had conducted the visits and provided OT services. However, the OT notes showed a signature authentication with OT 1’s name but did not include her professional license credential. On 3/26/25 at 1315 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above finding.

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Partial Extended Recertification surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN; 39539, HFEN; and 39210, HFEN. The survey team entered the HHA on 5/9/22 at 0830 hours. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: P&P: Policy and Procedure

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their comprehensive emergency preparedness program was based on the facility and community based risk assessment, utilizing an all hazards approach. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 5/16/22. The agency's P&P tiled Emergency Preparedness Policy revised 8/30/19, showed the community hazards assessment was completed. However, the agency's emergency preparedness plan failed to include the facility based risk assessments and strategies for addressing hazards or emergency events identified by the facility risk assessments. On 5/18/22 at 1141 hours, an interview and concurrent record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to follow up with on-duty staff and patients to determine services needed and procedures to inform the state and local officials of any on-duty staff or patients they are unable to contact. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 5/16/22. The agency's Natural Disasters/ Emergency P&P revised date 2015 showed the Phone Communication Plan will be initiated to notify personnel and community authorities, as appropriate personnel must listen to the organization- identified Emergency Broadcasting System for organization instructions and updates, if the telephone system is not functioning, and leadership staff is unable to initiate the Phone Communication Plan. However, the agency's Emergency Preparedness Plan P&P did not include the procedures to follow up with any on-duty staff or patients they are unable to contact, or procedures to communicate with state and local officials of any on duty staff or patients they are unable to contact. On 5/18/22 at 1121 hours, an interview and concurrent record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the above findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's emergency preparedness P&P addressed the use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness was conducted on 5/16/22. The agency's Emergency Management Plan revised 2015 showed the Administrator and supervisory personnel will be responsible for identifying and assigning staff to cover all essential functions. In addition, following the initiation of the Phone Communication Plan, all available and qualified personnel will be mobilized to perform identified services. However, the agency's emergency preparedness P&P and plan did not include the use of volunteers in an emergency and other emergency staffing strategies to address surge needs, including which external staffing agencies to be used, or the role for the integration of State and Federal designated health care professionals to address surge needs during an emergency. On 5/18/22 at 1121 hours, an interview and concurrent record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included the updated name and contact information of the patients' physicians. This failure had the potential to negatively impact the patients' care needs during the emergency events. Review of the agency's emergency preparedness plan was conducted on 5/16/22. Review of the the agency's Emergency Management Plan revised 2015 showed in the event of a prolonged emergency situation, the Executive Director/ Administrator or designee will notify the attending physicians regarding their ability to continue caring for their patients. However, the agency's emergency preparedness plan did not include the contact information for the patients' physicians. On 5/18/22 at 1121 hours, an interview and concurrent record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the exercises to test the emergency plan was conducted at least annually. This failure created the risk of the HHA's staff not knowing what to do in case of emergency. Review of the agency's P&Ps titled Emergency Management Plan revised 2015 was conducted on 5/16/22. The agency's P&Ps titled Emergency Management Plan revised 2015 showed the agency will test the emergency management plan at least annually, either in response to an actual emergency, or in a planned exercise. All actual responses and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical and support staff. Documentation will be used to identify deficiencies and opportunities for improvement based on all monitoring activities and observations during the exercise or actual emergency. The documentation will identify the effectiveness of the preparedness, mitigation, response and recovery activities of the emergency operations plan. However, review of the agency's documents failed to show documented evidence the agency had conducted the emergency preparedness exercises annually as per P&P. On 1/11/22 at 0900 hours, an interview and concurrent record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent Partial Extended Recertification and Emergency Preparedness surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN; 39539, HFEN; and 39210, HFEN. The survey team entered the HHA on 5/9/22 at 0830 hours. The survey team conducted 7 home visits and reviewed 12 active and 5 closed clinical records. Glossary: BID: two times a day BP: blood pressure bpm: beat(s) per minute cc: cubic centimeter CDC: Centers for Disease Control and Prevention CHHA: Certified Home Health Aide COVID-19: an infectious disease caused by the SARS-CoV-2 virus Diastolic Blood Pressure: (the second number or bottom number, indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats) DPCS: Director of Patient Care Services F: Fahrenheit FDA: Food Drug and Administration gm: gram(s) Hepatitis: inflammation of the liver HHA: Home Health Agency HS: hour of sleep IV: Intravenous LLE: Left Lower Extremity LVN: Licensed Vocational Nurse mcg; microgram(s) mEq: milliequivalent mg: milligram(s) ml: milliliter(s) mmHg: milliliter mercury NPO: nothing by mouth NS: Normal Saline OASIS: Outcome and Assessment Information Set OT: Occupational Therapy/ Therapist P&P: Policy and Procedure PCG: Patient Caregiver PEG: Percutaneous Endoscopic Gastrostomy PICC: Peripherally Inserted Central Catheter PO: by mouth POC: Plan of Care PRN: As Needed PT: Physical Therapy/Therapist PI: Performance Improvement Q: Every QAPI: Quality Assurance and Performance Improvement (process used to ensure services are meeting quality standards) QD: daily RLE: Right Lower Extremity RN: Registered Nurse ROC: Resumption of Care SN: Skilled Nursing/Nurse SNV: Skilled Nurse Visit ST: Speech Therapy/Therapist Stage 1 Pressure Injury: superficial reddening of the skin Stage 2 Pressure Injury: Partial thickness loss of skin with exposed dermis Stage 3 Pressure Injury: Full- thickness skin loss in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present. SOC: Start of Care Systolic Blood Pressure: (the first number or top number; indicates how much pressure your blood is exerting against your artery walls when the heart beat) TB: Tuberculosis (a highly infectious lung disease) Tetanus: a bacterial infection that causes painful muscle spasms TID: three times a day UTI : urinary tract infection W: Week

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (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: This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to implement their P&P related to the grievances for three nonsampled patients (Patients A, B, and C), creating the risk of violating the patients' rights and not providing quality of care and services to these patients. Review of the agency's P&P titled Complaint/ Grievance Process (undated) showed the organization personnel receiving the complaint will discuss, verbally and in writing the grievance with the clinical supervisor within five days of being notified of the alleged grievance. The clinical supervisor will investigate the grievance within five 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 days of receipt. Further review of the P&P showed the resolution information will be communicated in writing to the patient or his/ her representative filing the complaint. Review of the agency's grievance log showed the following grievances: - A complaint was filed by Patient A's family member on 12/21/21, regarding the visits by the OT and PT. The complaint showed the OT had two missed visits but never reached out to the patient. In addition, the PT told the patient that he was "too busy" to see Patient A on 12/14 and 12/17/21. The documentation showed the Clinical Manager discussed via text with the staff involved in the patient care. * However, the investigation did not include information regarding the OT's two missed visits, or the statements made by the PT. In addition, the complaint investigation failed to show documented evidence the Clinical Manager had communicated the resolution information in writing to the patient or patient's representative as per the agency's P&P. - A complaint was filed by Patient B's family member on 2/10/22, regarding Patient B's visits by the PT. The complaint showed the PT was not spending enough time with Patient B and wanted Patient B to be seen three times a week. The documentation showed the Clinical Manager spoke with the PT involved via text. However, the investigation did not include the details of the electronic message regarding the above complaint. There was no documented evidence showing the Clinical Manager had communicated the resolution information in writing to the patient or the patient's representative as per the agency's P&P. - A complaint was filed by Patient C's family member on 8/17/20, regarding Patient C's OT and PT visits. The complaint showed the OT attempted to contact Patient C for a reevaluation while Patient C and the family were out of town and did not attempt to contact Patient C after this. The OT discharged the patient with the assumption that Patient C refused OT services. The complainant added the PT said Patient C was too old to progress. The documentation showed the Clinical Manager was provided instructions to contact the patient's family member via email and alternative contact phone number if unable to reach Patient C; and the physician notified. However, there was no documented evidence the Clinical Manager had communicated a resolution in writing on the grievance as per the agency's P&P. On 5/18/22 at 1142 hours, an interview and concurrent agency record review was conducted with Clinical Manager 3 and RN 1. Clinical Manager 3 and RN 1 were informed and acknowledged the findings.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs for nine of 17 sampled patients (Patients 2, 3, 4, 5, 7, 10, 11, 12, and 14). This failure created the risk of not identifying and addressing the care needs timely for these patients. 5a. Review of Patient 2's clinical record showed the SOC was 5/20/21. The clinical record showed the patient received home health services during the certification period from 3/14/22 to 5/12/22. Review of the Recertification OASIS dated 3/10/22, showed an assessment revealing Patient 2 had a Stage 2 pressure injury on the left gluteus; three surgical wounds to the AV shunt site, L tip of ear, and Left side of face; and a left lower extremity abrasion/ callous. Further review of the Recertification OASIS, included a note showing Patient 2 sustained two trauma wounds to the left and right lower extremities during a fall. However, review of the clinical record showed no documented evidence the pressure injury, or left and right abrasions were assessed properly, to include the wound measurement. b. Review of the Recertification OASIS dated 3/10/22 and review of the SOC OASIS dated 1/18/21, showed Patient 2 was on dialysis and had a AV graft/ fistula to the Left Upper arm. Further review of the assessment failed to show information on the dialysis center's phone number and contact person. On 5/18/22 at 0957 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Managers 2 and RN 1 verified the above findings. 6. Review of Patient 11's clinical record showed the SOC was 3/18/22. The clinical record showed the patient received home health services during the certification period from 3/18/22 to 5/16/22. Review of the SOC OASIS dated 3/18/22, showed an incomplete assessment of Patient 11’s most recent immunizations including TB, Tetanus, and Hepatitis. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Managers 2 and RN 1 were informed and acknowledged the findings. 7. Review of Patient 5's clinical record showed the SOC was 3/24/22. The clinical record showed the patient received home health services during the certification period from 3/24/22 to 5/22/22. Review of the SOC OASIS dated 3/24/22, showed an incomplete assessment of Patient 5’s most recent immunizations including TB, Tetanus, and Hepatitis. Further review of the SOC OASIS, failed to show documented evidence a cultural assessment was conducted on Patient 5. On 5/18/22 at 0945 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Managers 2 and RN 1 were informed and acknowledged the findings. 8. Review of Patient 12's clinical record showed the SOC was 2/23/22. The clinical record showed the patient received home health services during the certification period from 2/23/22 to 4/23/22. Review of the SOC OASIS dated 2/23/22, showed an incomplete assessment of Patient 12’s most recent immunizations including TB, Tetanus, and Hepatitis. On 5/18/22 at 0959 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the finding. 9. Review of Patient 7's clinical record showed the SOC was 4/12/22. The clinical record showed the patient received home health services during the certification period from 4/12/22 to 6/10/22. Review of the SOC OASIS dated 4/12/22, showed an incomplete assessment of Patient 7’s most recent immunizations including TB, Tetanus, and Hepatitis. On 5/18/22 at 0820 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the finding. 1. Review of the agency's P&P titled Initial and Comprehensive Assessment (undated) showed during the initial and comprehensive patient assessments, all baseline data to be used in measuring the patient's progress towards goals and other relevant information will be documented in the patient's clinical record, including the patient's medical and psycholosocial history, pertinent diagnoses and prognosis, cultural and religious practices, and immunizations. Review of Patient 3's clinical record showed the SOC was 12/12/21. The clinical record showed the patient received home health services during the certification period from 2/10/22 to 4/10/22. Review of the ROC OASIS dated 3/11/22, showed no documented evidence the health screening was assessed. The form also showed incomplete assessment of Patient 3’s most recent immunizations including TB, Tetanus, and Hepatitis. On 5/18/22 at 0837 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. 2. Review of Patient 4's clinical record showed the SOC was 3/14/22. The clinical record showed the patient received home health services during the certification period from 3/14/22 to 5/12/22. Review of the SOC OASIS dated 3/14/22, showed no documented evidence the health screening and cultural section were assessed. On 5/18/22 at 0840 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. 3. Review of Patient 10's clinical record showed the SOC was 2/4/22. The clinical record showed the patient received home health services during the certification period from 4/5/22 to 6/3/22. Review of the Recertification OASIS dated 4/4/22, showed a note revealing Patient 3 had a Stage 1 pressure injury on the coccyx (tailbone); however, further review of the clinical record showed no documented evidence the pressure injury was assessed properly, including the wound measurement. On 5/18/22 at 0957 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 verified the findings. 4. Review of Patient 14's clinical record showed the SOC was 3/18/21. The clinical record showed the patient received home health services during the certification period from 3/18/21 to 5/16/21. Review of the SOC OASIS dated 3/18/21, showed no documented evidence the cultural section was assessed. On 5/18/22 at 1100 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 verified the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were updated for six of 17 sampled patients (Patients 1, 2, 4, 5, 6, and 7), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. 2. Review of Patient 2's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 1/18/21. The patient was certified for home health services during the certification periods from 3/14/22 to 5/12/22. The POC, for the certification period from 3/14/22 to 5/12/22, cited SN visits 1-3w8, 1-2w1, and 2 as needed visits for change in condition. Review of Patient 2's medication profile for the certification period 3/14/22 to 5/12/22 showed the following medications: Phosphorus 300mg three tablets, oral, three times a day; Sevelamer Carbonate oral 800mg two tablets, with each meal daily; Icosapent Ethyl oral 1g, one capsule three times daily; Gabapentin oral 300mg, one capsule, daily at bedtime; Allopurinol oral 100mg, one tablet daily; Renal multivitamins formula oral, one tablet, daily; Tylenol oral 325mg, two tablets, every four hours as needed for pain; Imodium oral, 2mg, one tablet daily as directed for loose stools/ diarrhea; Miralax Oral 17gm, one packet daily as needed for constipation; Tramadol HCl oral 50 A joint home visit with RN 4 was conducted on 5/10/22 at 1030 hours, to Patient 2's home. Review of Patient 2's medications showed Patient 2 was on the following medications: Velphoro oral 500mg , two tablets by mouth, three times a day; Amlodipine Besylate 5mg, one tablet, by mouth daily; Furosemide 80mg, one tablet, by mouth; Insulin Glargine, subcutaneous, 100U/ml, 48 units subcutaneous daily; Icosapent oral 1g, one capsule three times daily; Gabapentin oral 300mg, one capsule daily; Levothyroxine Sodium 50mg, two tablets, in the morning; Tramadol oral 500mg, one tablet, every six hours as needed for pain; Miralax 17gm, one packet, daily as needed for constipation; Imodium D oral 2mg, one tablet as needed for loose stool; Tylenol oral 325mg, two tablets, every four hours as needed for pain; Renal Multivitamin one tablet, oral, daily; Allopurinol 100mg, one tablet, by mouth, daily; Senokot ES 17gm, two tablets daily, as needed. mg, one tablet, every six hours as needed for pain; and Levothyroxine Sodium oral 50mcg, two tablets in the morning. A review of Patient 2's medications was conducted with RN 4 and PCG shared the following information: - Patient 2 was no longer taking the following medications: Phosphorus 300mg three tablets, oral, three times a day; Sevelamer Carbonate oral 800mg two tablets, with each meal daily; Miralax Oral 17gm; and Levothyroxine Sodium oral 50mcg, two tablets in the morning; and Imodium oral, 2mg, one tablet daily as directed for loose stools/ diarrhea. PCG was not aware Patient 2 was on a renal multivitamin - Patient 2 also was on Gabapentin 100mg, one capsule daily at bedtime; Allopurinol 300mg, one tablet, by mouth daily; Senakot 17.2mg one tablet, daily as needed; Lasix 80mg one tablet, by mouth, daily; and Insulin Glargine, inject 48 units every morning. Review of Patient 2's medication profile and medications showed, the Patient 2's list of medications at home was not updated during the review with the patient's caregiver. On 5/10/22 at 1030 hours, an interview with concurrent clinical record review was conducted with RN 4. RN 4 was informed and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 3/24/22. The patient was certified for home health services during the certification periods from 3/24/22 to 5/22/22. The POC, for the certification period from 3/24/22 to 5/22/22, cited SN visits 1-2w2, 1w4, and 2 as needed visits for change in condition. Review of Patient 5's medication profile for the certification period 3/14/22 to 5/12/22 showed the following medications: - Lisinopril Oral 5mg, one tablet, by mouth, BID; Amiodarone HCl Oral 200mg, 1/2 tablet, by mouth daily; Eliquis Oral 2.5mg, one tablet, by mouth, BID; Atenolol Oral 50mg, one tablet, by mouth, BID; Atorvastatin Calcium Oral 10mg, one tablet, by mouth, every night at bedtime; Bupropion HCl Oral 100mg, one tablet, by mouth, BID; Metformin HCl Oral 500mg, one tablet, by mouth, BID; Brilinta Oral 90mg, one tablet, by mouth, BID; Glipizide Oral 5mg, one tablet, by mouth, daily; Omeprazole Oral 20mg, two tablets, by mouth, daily; Levothyroxine Sodium Oral 75mcg, one tablet, by mouth, daily; Advil Oral 200mg, one tablet, by mouth, every four hours as needed for pain; Vitamin C Oral 500 mg, one tablet, by mouth, daily; Lasix Oral 20mg, one tablet, by mouth, daily. A joint home visit with RN 5 was conducted on 5/10/22 at 0900 hours, to Patient 5's home. Review of Patient 2's medications with RN 5 and PCG shared Patient 5 was no longer taking the following medications: - Brilinta Oral 90mg, one tablet, by mouth, BID; - Glipizide Oral 5mg, one tablet, by mouth, daily; - Omeprazole Oral 20mg, two tablets, by mouth, daily; and - Lasix Oral 20mg, one tablet, by mouth, daily. Review of Patient 5's medication profile and medications showed, the Patient 5's list of medications at home was not updated during the review with the PCG. On 5/10/22 at 0900 hours, an interview with concurrent clinical record review was conducted with RN 4. RN 4 was informed and acknowledged the finding. 4. Review of Patient 6's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 4/21/22. The patient was certified for home health services during the certification periods from 4/21/22 to 6/19/22. The POC, for the certification period from 4/21/22 to 6/19/22, cited SN visits 1w1, 1-2w1, and 1w3. Review of the Patient Medication Record dated 4/21/22, showed current medications included the following: Amlodipine Besylate Oral 5mg, one tablet nightly; tramadol HCl Oral 50mg one tablet, every six hours as needed for pain; Aspirin oral 81mg, one tablet daily; Senna Oral 8.6mg 1-2 tablets nightly as needed for constipation; Tamsulosin HCl Oral 0.4ml, one capsule daily; Tylenol Oral 325mg, two tablets every 4 hours as needed for pain; Nitro-Dur transdermal 0.2mg/ Hr, one patch daily to left foot only; Vitamin D3 oral 50mcg, one capsule, three times daily; Miralax Oral 17gm, one packet daily, as needed for constipation; Preparation H External 1%, one application to affected area up to three times a day as needed for hemorrhoids; Losartan Potassium- HCTZ Oral 100-25mg, one tablet, by mouth daily; Zinc Oral 50mg, one tablet, by mouth, daily; Fluconazole Oral 200mg, one tablet, by mouth daily; Lactobacillus Oral two capsules, by mouth once daily; Rosuvastatin Calcium Oral 5mg, one tablet, by mouth every evening; Tamsulosin HCl oral 0.4mg, one capsule, by mouth after breakfast; Docusate Sodium Oral 100mg, one capsule, by mouth, twice daily; Senna Oral 8.6mg, two tablets, by mouth daily as needed for constipation; Finasteride Oral 5mg, one tablet, take by mouth, every morning; Multivitamins Oral 1 tablet, by mouth once a day. A joint home visit with CHHA 2 was conducted on 5/10/22 at 1010 hours, to Patient 6s home. Review of the patient’s medications was conducted with CHHA 2 and PCG showed the Medication Profile form was blank. Review of Patient 6's medications with CHHA 2 and Patient 6's caregiver shared the following information: - Patient 2 was no longer taking the following medications: Preparation H External 1%, one application to affected area up to three times a day as needed for hemorrhoids; Fluconazole Oral 200mg, one tablet, by mouth daily; - Patient 2 was taking Vitamin D3 oral 50mcg, one capsule, once daily; On 5/18/22 at 1010 hours, an interview with concurrent clinical record review was conducted with CHHA 2. CHHA 2 was informed and acknowledged the finding. 5. Review of Patient 7's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 4/12/22. The patient was certified for home health services during the certification periods from 4/12/22 to 6/10/22. The POC, for the certification period from 4/12/22 to 6/10/22, cited SN visits 1-2w1, and 1w1. Review of the Patient Medication Record dated 4/12/22, showed current medications included the following: - Amlodipine Besylate Oral 5mg, one tbalet by mouth daily; - Apixaban Oral 5mg, one tablet, by mouth, BID; - Senna- Docusate Sodium Oral 8.6- 50mg, two tablets, BID; - Insulin Glargine Subcutaneous inject 50 units, BID; - Insulin Lispro Subcutaneous 100 units/ ml, inject per sliding scale; - Montelukast Sodium Oral 10mg, one tablet, by mouth at bedtime; - Advil oral 200mg, three tablets, by mouth take 600mg every 12 hours as needed for pain; A joint home visit with the OT was conducted on 5/11/22 at 1230 hours, to Patient 7's home. Review of the patient’s medications was conducted with the OT and PCG. Patient 7's PCG stated the patient did not have the Amlodipine (medication for BP) for a while now, because they did not have a supply of the medication and were awaiting for a evaluation from the PCP. The PCG had stated they had relayed the information to the SN. On 5/18/22 at 0820 hours, an interview with concurrent clinical record review was conducted with the Clinical Manager 3. Clinical Manager 3 stated there were no documented evidence the SN had followed up with Patient 7's medication. Clinical Manager 3 was informed and acknowledged the finding. 6. Review of Patient 1's clinical record was initiated on 5/11/22. The clinical record showed the SOC was 2/11/22. The patient was certified for home health services during the certification periods from 4/12/22 to 6/10/22. The POC, for the certification period from 4/12/22 to 6/10/22, cited SN visits 1-2w4, and 1w5. Review of the Patient Medication Record dated 4/7/22, showed current medications included the following: - Levothyroxine Soidum Oral 25mcg, 1 tablet, by mouth, every morning on empty stomach before breakfast; - Aspirin Oral 81mg, one tablet, by mouth once daily - Torsemide Oral 10mg, one tablet, by mouth, once daily as needed leg edema - Potassium Chloride ER Oral 10mEq, one tablet by mouth once daily as needed when taking Torsemide - Metoprolol Tartrate Oral 25mg, 1/2 tablet, by mouth, twice a day; - Midodrine HCl Oral 5mg, one tablet, by mouth, BID; - Lisinopril Oral 2.5mg, one tablet, by mouth, QAM - Lipitor Oral 40mg, one tablet, by mouth, QPM - Pantoprazole Sodium Oral 40mg, one tablet, by mouth, daily before breakfast; - Xarelto Oral 20mg, one tablet, by mouth daily, A joint home visit with RN 1 was conducted on 5/11/22 at 1201 hours, to Patient 1's home. Review of the patient’s medications was conducted with RN 1. Patient 1's medication profile showed an additional medication not listed in the Patient Medication Record as the following: - Clopidogrel 75mg, one tablet, by mouth, twice a day; and - Potassium Chloride ER 10mEq, one tablet, by mouth, everyday with food On 5/18/22 at 1035, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the findings. 1. Review of the agency's P&P titled Medication Profile (undated) showed patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Review of Patient 4's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 3/14/22. The patient was certified for home health services during the certification period from 3/14/22 to 5/12/22. The POC, for the certification period from 3/14/22 to 5/12/22, cited PT visits 1-2W5. The Medication Profile showed the patient’s medications included the following: -amlodipine (used to treat high blood pressure) 10 mg one tablet by mouth daily as needed for BP; -pantoprazole (used to decrease the acid produced in the stomach) 40 mg one tablet by mouth daily; -aspirin (used to relieve fever and mild to moderate pain) 81 mg one tablet by mouth daily; -quetiapine (antipsychotic) 25 mg one tablet by mouth daily; and -levothyroxine (used to treat underactive thyroid gland) 25 mcg one tablet by mouth daily before breakfast. On 5/10/22 at 0900 hours, a joint home visit was conducted with PT 1 to Patient 4's home. Review of the patient’s medications with the PT and PCG showed the patient was also taking cranberry with vitamin C (supplement) and senna (used to treat constipation) 8.6 mg by mouth daily; however, these medications were not listed in the patient’s medication profile. On 5/10/22 at 0920 hours, an interview and concurrent clinical record review was conducted with PT 1. PT 1 was informed and acknowledged the findings.

Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient's primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to perform assessment of the patient's PCG for ability to provide care related to IV medication administration for one of 17 sampled patients (Patient 15) creating the risk of not providing safe quality care and services to this patient. Review of Patient 15's closed clinical record was initiated on 5/12/22. The closed clinical record showed the SOC was 9/6/20. The patient was certified for home health services during the certification periods from 9/6/20 to 11/4/20, and 12/20/21 to 1/25/22. The POC, for the certification period from 12/20/21 to 1/25/22, showed the following: - Thiamine HCl (a vitamin) injection 100 mg/ml 100 mg in 1000 ml normal saline IVPB to infused over four to six hours via PICC line Q other day. In addition, the POC showed the SN goals including to infuse 1000 ml of normal saline with Thiamine 10 mg via PICC line three times weekly as ordered. - SN visits 1W1 and 1-2W8 Review of the patient's Recertification OASIS dated 12/28/21, showed Patient 15 received IV hydration via PICC line Q other day, which was administered by the SN or the patient's daughter, and the PICC line was flushed BID to avoid clotting. Review of the Medication Administration Record dated 12/30/21, 1/4, 1/6, 1/11, 1/13, 1/18, and 1/20/22, showed the SN administered 1000 ml of normal saline with Thiamine 10 mg via PICC line. Further review of the clinical record failed to show the SN administered the IV hydration three times weekly as per POC. Further review of the clinical record failed to show documented evidence Patient 15's family had a competency assessment for IV medication administration. On 5/18/22 at 0920 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 stated they did not have a P&P related to the family/PCG competency for the administration of IV medications. Clinical Manager 3 was informed and acknowledged the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POCs addressed specific interventions related to the patient’s care and treatment for six of 17 sampled patients (Patients 2, 3, 4, 9, 10, and 14). These failures created the risk for the patients not receiving the individualized care and services necessary to improve the patients’ health status. 6. Review of Patient 2's clinical record showed the SOC was 1/18/21. The clinical record showed the patient received home health services during the certification period from 3/14/22 to 5/12/22. The POC, for the certification period from 3/14/22 to 5/12/22 , showed the following treatment/ interventions: - Cleanse with wound cleanser, apply Calmoseptine ointment to the wound BID and as needed. SN to perform wound care every week and caregiver to apply daily and as needed; - Tramadol HCl Oral 50mg, one tablet every six hours prn pain; - Tylenol Oral 325mg, two tablets every four hours as prn pain. However, further review of the POC showed the SN interventions included the wound site for the wound care order and failed to indicate the as needed application of Calmoseptine ointment. In addition, the POC listed medications to administer for pain, however there were no specific indications showing which pain medication to be used first. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN1. Clinical Managers 2 and RN 1 were informed and acknowledged the findings. 1. Review of Patient 3's clinical record showed the SOC was 12/12/21. The clinical record showed the patient received home health services during the certification periods from 2/10/22 to 4/10/22 and 4/11/22 to 6/9/22. The POC, for the certification periods from 2/10/22 to 4/10/22 and 4/11/22 to 6/9/22, showed the following medications listed: -normal saline 1000 ml to be infused intravenously via the left upper arm PICC line over four hours, one to two times weekly PRN; -heparin sodium lock flush 5 ml IV push into each lumen of the patient’s PICC line, once weekly and PRN; and -normal saline flush 10 ml IV push into each lumen of the PICC line, once weekly and PRN. The medications listed showed to administer each medication PRN; however, there was no specific indication showing what these medications should be given for. On 5/18/22 at 0838 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings. 2. Review of Patient 4's clinical record showed the SOC was 3/14/22. The clinical record showed the patient received home health services during the certification period from 3/14/22 to 5/12/22. The POC, for the certification period from 3/14/22 to 5/12/22, showed the following medications listed: -amlodipine 10 mg one tablet daily as needed for blood pressure; -lidocaine one patch daily, on 12 hours and off 12 hours, as needed; and -acetaminophen 500 mg by mouth two capsules every six hours as needed. The medications listed showed to administer each medication PRN; however, there was no specific indication showing what these medications should be given for, including the blood pressure parameter for amlodipine. On 5/18/22 at 0843 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings. 3. Review of Patient 9's clinical record showed the SOC was 11/20/21. The clinical record showed the patient received home health services during the certification periods from 1/4/22 to 3/14/22 and 3/15/22 to 5/13/22. The POC, for the certification periods from 1/4/22 to 3/14/22 and 3/15/22 to 5/13/22, showed to administer Tylenol 500 mg two tablets by mouth every four hours as needed for mild to moderate pain and Ultram 50 mg one tablet by mouth every six hours as needed for moderate pain; however, there was no specific indication showing which medication to give specifically for moderate pain. In addition, the POC for the certification period from 1/14/22 to 3/14/22, cited HHA visits 1W8; however, the interventions cited for HHA visits 2W4 for assistance with ADLs which was inconsistent. On 5/18/22 at 0855 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings. 4. Review of Patient 10's clinical record showed the SOC was 2/4/22. The clinical record showed the patient received home health services during the certification period from 4/5/22 to 6/3/22. The POC, for the certification period from 4/5/22 to 6/3/22, cited HHA visits 1-2W4; however, the interventions cited for HHA visits 2W4 for assistance with ADLs which was inconsistent. In addition, the POC also showed to administer Tylenol 15-30 ml via PEG tube every eight to 12 hours PRN for pain; however, there was no indication when to administer 15 ml versus 30 ml. On 5/18/22 at 0957 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 were informed of the findings. 5a. Review of Patient 14's clinical record showed the SOC was 3/18/21. The clinical record showed the patient received home health services during the certification periods from 3/18/21 to 5/16/21 and 5/17/21 to 6/2/21. The POC, for the certification periods from 3/18/21 to 5/16/21 and 5/17/21 to 6/2/21, showed to administer Tylenol 500 mg one tablet by mouth every four to six hours PRN for pain and hydrocodone-acetaminophen 5-325 mg one tablet by mouth every six hours PRN for pain; however, there was no specific indication showing when to give Tylenol versus hydrocodone-acetaminophen. b. Review of the SOC OASIS dated 3/18/21, showed Patient 14 had multiple wounds located at the midline abdomen, right upper abdomen, left upper abdomen, right outer midline abdomen, and right lower abdomen which were identified as wound numbers one to five respectively. The POC, for the certification period from 3/18/21 to 5/16/21, addressed the goals for wounds one, three, four, and five; however, there was no documented evidence showing the goals for wound number two. In addition, further review of the POC showed the following wound care orders: -wound care: cleanse with NS or wound care spray, perform staple care, pat dry, and leave open to air. Wound care was to be performed daily. Patient was to perform wound care on non-SN days. -wound care: cleanse with NS or wound care spray, pat dry, pack with iodoform steri strips, and cover with bordered foam dressing. Wound care was to be performed every other day and PRN if soiled or dislodged. -wound care: cleanse with NS or wound care spray, pat dry, cover with adaptic, and cover with dry sterile dressing. Wound care was to be performed every other day and PRN if soiled or dislodged. -wound care: cleanse with NS or wound care spray, perform stitch care, pat dry, cover with split gauze, cover with dry sterile dressing, and secure with Hypafix. Wound care was to be performed every other day. The POC addressed the wound care orders; however, it did not specify the wound sites. On 5/18/22 at 1100 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 verified the findings.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the verbal orders were signed by the physician in a timely manner for two of 17 sampled patients (Patients 3 and 16). This failure created the risk of not appropriately authenticating the contents of the patients' clinical record. Review of the HHA state regulation Title 22 Chapter 6 74697 (a) A written plan of treatment shall be established for each patient whose care requires medical orders. A plan of treatment or plan or care for patients requiring medical orders shall be (a) approved and signed within 30 working days by the attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice. 1. Review of Patient 3’s clinical record was initiated on 5/9/22. The clinical record showed the SOC was 12/12/21. The patient was certified for home health services during the certification period from 2/10/22 to 4/10/22. The Physician Order cited SN visits 1-2W4 with 3 PRN visits for changes in condition, dressing changes, and hydration effective 3/16/22. The order was electronically signed by the RN on 3/16/22. However, the order was signed by the physician on 5/11/22. On 5/18/22 at 0943 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the finding. 2. Review of Patient 16’s clinical record was initiated on 5/12/22. The clinical record showed the SOC was 3/18/21. The patient was certified for home health services during the certification period from 7/16/21 to 9/10/21. Review of the Physician Order showed the wound care order was electronically signed by the RN on 9/6/21. However, the order was signed by the physician on 1/11/22. On 5/18/22 at 0943 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the finding.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to revise and update the POC for one of 17 sampled patients (Patient 14). This failure created the risk for not providing the necessary care and services to the patient. Review of the agency's P&P titled Care Planning Process (undated) showed the plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patients. Revision dates will be noted on the plan of care. Review of Patient 14's clinical record showed the SOC was 3/18/21. The clinical record showed the patient received home health services during the certification period from 5/17/21 to 6/2/21. The POC, for the certification period from 5/17/21 to 6/2/21, showed the nutritional requirements included regular and full liquid diet for four days. Review of the Recertification OASIS dated 5/13/21, showed a comment written by the SN showing the patient was now tolerating a regular diet. However, there was no documented evidence showing the POC was revised and updated to reflect the most current assessment of the patient’s nutritional requirements. On 5/18/22 at 1100 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 verified the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved 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 communication with the physician related to the patient's condition for three of seventeen sampled patients (Patients 5, 9, and 11). This failure had the potential to delay the necessary care and services to the patients. 2. Review of Patient 11's clinical record was initiated on 5/11/22. The clinical record showed the SOC was 3/18/22. The patient was certified for home health services during the certification period from 3/18/22 to 5/16/22. The POC, for certification period from 3/18/22 to 5/16/22, showed nutritional requirements included mechanical soft, heart healthy, low cholesterol, and low fat diet. Further review of the POC showed the SN to assess patient for diet compliance. In addition, ST evaluation when authorization received. Review of the SOC OASIS dated 3/18/22 showed Patient 11 was assessed to have dysphagia, with a right facial droop. The SN instructed to prepare mechanical soft foods until patient is evaluated by speech therapy (ST). Review of the Patient Communication dated 3/18/22, showed RN recommended ST evaluation for dysphagia and speech. Review of the SN notes dated 3/21, 3/24, and 3/28 showed Patient 11's daughter feeding regular diet not soft. SN reinforced soft foods to prevent aspiration until ST evaluation. However, further review of the clinical record failed to show documentation, the SN coordinated with the MD and ST regarding the family feeding the patient regular foods. Review of the ST note dated 3/30/22, showed Patient 11's speech/ language were assessed. Further review of the clinical record showed a diagnosis of dysarthria. In addition, the reason for referral was left blank. Review of the ST Reevaluation note dated 4/22/22, showed patient is having some trouble eating some items and having coughing during intake. ST follow up and provide education on safe swallow strategies and diet modifications. Patient's daughter also reported patient's swallowing fluctuates and has lately been having more coughing while eating. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Managers 2 and RN 1 were informed and acknowledged the findings. 3. Review of Patient 5's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 3/24/22. The patient was certified for home health services during the certification period from 3/24/22 to 5/22/22. The POC, for certification period 3/24/22 to 5/22/22, showed to notify the physician of the follow parameters: - Temperature greater than 100 or less than 96; - Pulse greater than 100 or less than 60; - Respirations greater than 24 or less than 14; - Systolic BP greater than 160 or less than 90; - Diastolic BP greater than 90 or less than 60; - Oxygen saturation less than 90%. Review of the SN note dated 3/28/22, showed pulse of 50, and BP of 170/ 84. Further review of the SN note failed to show documented evidence the physician was notified of the BP and pulse measurements, as per POC. Review of the SN note dated 4/16/22, showed pulse of 54, and BP of 154/ 74. Further review of the SN note failed to show documented evidence the physician was notified of the pulse measurements, as per POC. On 5/18/22 at 0945 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Managers 2 and RN 1 were informed and acknowledged the findings. 1. Review of the agency's P&P titled Care Planning Proces (undated) showed the clinicians will inform the patient's physician of any changes that suggest a need to alter the plan of care. Review of Patient 9's clinical record showed the SOC was 11/20/20. The clinical record showed the patient received home health services during the certification period from 3/15/22 to 5/13/22. Review of the HHA Visit notes dated 4/9/22, showed the CHHA identified a bright rash on the patient’s buttocks and anus area. The CHHA documented the RN was aware of the skin condition. Review of the Skilled Nurse Visit notes dated 4/13/22, showed the SN visited the patient’s home. Under Skin Comments, the SN documented the patient had a red rash to the groin, labial folds, and buttocks which worsened over the past two days. Further review of the clinical record showed no documented evidence the SN had assessed the patient or notified the physician about the patient’s rash prior to the visit on 4/13/22. On 5/18/22 at 0913 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the finding.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to coordinate the necessary care services for three of 17 sampled patients (Patients 1, 9 and 17). This failure had the potential to negatively impact the patients' health status. 2. Review of Patient 1's clinical record showed the SOC was 2/11/22. The clinical record showed the patient received home health services during the certification period from 2/11/22 to 4/11/22 and 4/12/22 to 6/10/22. The POC, for the certification period from 2/11/22 to 4/11/22, cited HHA visits 1w4 when authorization received. Review of the Physician Order dated 2/17/22, showed Order HHA for bathing needs, 1-2w4, when authorization approved. Review of the Authorization requested date 2/24/22, showed the patient was approved for Home health aide visits and services, action date 3/9/22. However, further review of Patient 1's clinical record showed there was no documented evidence showing the CHHA had been scheduled to see the patient. On 5/18/22 at 1035 hours, an interview and concurrent record review was conducted with Clinical Manager 3. Clinical Manager 3 verified the finding. 1. Review of Patient 9's clinical record showed the SOC was 11/20/20. The clinical record showed the patient received home health services during the certification period from 1/4/22 to 3/14/22. The POC, for the certification period from 1/4/22 to 3/14/22, cited HHA visits 1W8. Review of Patient 9’s clinical record showed the CHHA visited the patient’s home on 2/3, 2/11, 2/18, 2/25, 3/4, and 3/11/22; however, there was no documented evidence showing the CHHA visited the patient’s home from 1/14 to 2/2/22. Review of the Missed Visit Forms dated 1/14, 1/21, and 1/28/22 showed the CHHA documented the reasons for the missed visits; however, there was no documented evidence showing the CHHA had attempted to visit the patient on a different day. There was also no documented evidence showing the physician was notified of the missed visits. On 5/18/22 at 0919 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the finding.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the SN visit schedule for four of 17 sampled patients (Patients 2, 3, 4, and 6) creating the risk of not providing the necessary information to these patients 3. Review of Patient 2's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 1/18/21. The patient was certified for home health services during the certification period from 3/12/22 to 5/12/22. The POC, for the certification period from 4/11/22 to 6/9/22, cited SN visits 1-3W8, 1-2w1, and 3 PRNs for changes in condition. A joint home visit with RN 3 was conducted on 5/10/22 at 1030 hours, to Patient 2's home. Review of the patient's admission packet provided by RN 3 showed no documented evidence of the written instructions outlining the SN visit schedule. On 5/10/22 at 1030 hours, an interview and concurrent clinical record review was conducted with RN 3. RN 3 was informed and acknowledged the findings. 4. Review of Patient 6's clinical record was initiated on 5/11/22. The clinical record showed the SOC was 4/21/22. The patient was certified for home health services during the certification period from 4/21/22 to 6/19/22. The POC, for the certification period from 4/21/22 to 6/19/22, cited SN visits 1w1, 1-2w1, 1w3 . A joint home visit with CHHA 2 was conducted on 5/10/22 at 1010 hours, to Patient 6's home. Review of the patient's admission packet provided by the PCG showed no documented evidence of the written instructions outlining the SN or CHHA visit schedule. On 5/10/22 at 1020 hours, an interview and concurrent clinical record review was conducted with CHHA 2. CHHA 2 was informed and acknowledged the findings. 1. Review of Patient 3's clinical record was initiated on 5/9/22. The clinical record showed the SOC was 12/12/21. The patient was certified for home health services during the certification period from 4/11/22 to 6/9/22. The POC, for the certification period from 4/11/22 to 6/9/22, cited SN visits 1-2W9 and 3 PRNs for changes in condition. A joint home visit with RN 2 was conducted on 5/10/22 at 1055 hours, to Patient 3's home. RN 2 was asked for the written instructions outlining the SN visit schedule. RN 2 replied there was no written instruction outlining the SN visit schedule provided to the patient. RN 2 stated she came to the patient’s house at the same day and time every week and would call the patient ahead of time to confirm the visit. Review of the patient's admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 5/10/22 at 1200 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings. 2. Review of Patient 4's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 3/14/22. The patient was certified for home health services during the certification period from 3/14/22 to 5/12/22. The POC, for the certification period from 3/14/22 to 5/12/22, cited PT visits 1-2W5. A joint home visit with PT 1 was conducted on 5/10/22 at 0900 hours, to Patient 4's home. PT 1 was asked for the written instructions outlining the PT visit schedule. PT 1 replied there was no written instruction outlining the PT visit schedule provided to the patient. PT 1 stated she only called the patient prior to visiting the patient’s home. Review of the patient's admission packet provided by the HHA showed no documented evidence of the written instructions outlining the PT visit schedule. On 5/10/22 at 0923 hours, an interview and concurrent clinical record review was conducted with PT 1. PT 1 was informed and acknowledged the findings.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the QAPI program included analysis of the collected data, implementation of the preventive actions, and evaluation of the current practices to improve the overall care and services provided to the patients. This failure had the potential to create a lack of systems for improvement which could affect the provision of quality care and services to the patients and their families. Review of the QAPI program for 2020 and 2021 was conducted on 5/17/22. The QAPI program showed the agency performed the QAPI studies based on the agency’s problem-prone areas. Further review of the QAPI program showed the data was collected for each PI study and identified specific problem areas. However, there was no documented evidence showing the agency had analyzed the data, implemented the preventive actions, and evaluated whether the current practices were effective in improving the overall care and services provided to the patients. On 5/17/22 at 1027 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. The Administrator/DPCS verified the findings. The Administrator/DPCS stated the QAPI Committee usually met twice a year to discuss and evaluate the effectiveness of the QAPI program; however, for the past two years, the agency’s priority shifted to COVID-19 infection prevention and that was why she was unable to provide any documentation regarding the QAPI program.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections. This failure had the potential to result in the transmission of infection to the staff, caregivers, and the vulnerable population of patients in their homes. Review of the agency’s Infection Control Program binder for the years of 2020, 2021, and 2022 was initiated on 5/15/22. The binder showed the agency collected the data of the patient specific infections monthly. However, there was no documented evidence showing the agency thoroughly analyzed the data, investigated for possible causes of each infection identified, tracked the patterns and trends of infections, and implemented specific actions to minimize infections to improve care practices and control the transmission of infection among the staff, caregivers, and patients. There was documentation showing the agency tallied the number of infections yearly; however, the total number of infections documented did not match the data collected monthly. For example, the document titled 2021 Infection Surveillance Totals showed there was a total of 60 UTIs identified in 2021; however, the data collected monthly showed a total of 101 UTIs as follows: - For January, there were seven UTIs identified; - For February, there were six UTIs identified; - For March, there were five UTIs identified; - For April, there were 10 UTIs identified; - For May, there were 12 UTIs identified; - For June, there were six UTIs identified; - For July, there were five UTIs identified; - For August, there were nine UTIs identified; - For September, there were seven UTIs identified; - For October, there were 11 UTIs identified; - For November, there were 10 UTIs identified; and - For December, there were 13 UTIs identified. In addition, the document titled UTI Data Collection 2021 showed there was a total of 30 UTIs identified, which was also inconsistent with the actual number of UTIs identified for 2021. On 5/17/22 at 1008 hours, an interview and concurrent document review was conducted with Clinical Manager 3. Clinical Manager 3 was asked how the infection control program was implemented in the agency. Clinical Manager 3 stated prior to 2022, the staff would report to the clinical managers whenever their patients had a new infection, and the clinical managers would then document this information in the infection surveillance log. Currently, the staff could enter the information about new infections directly into the software. When asked what actions were taken after the data was collected, Clinical Manager 3 replied the staff would follow-up in a few days to see whether there was any improvement in the patient’s condition. The Administrator/DPCS would also tabulate the total number of infections. When asked to show documentation of the analysis and corrective actions to prevent and minimize the recurrence of infections, Clinical Manager 3 was unable to do so and stated she was not involved in the implementation of the infection prevention program beyond the data collection. On 5/17/22 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. When asked what actions were taken after the data was collected, the Administrator/DPCS stated she would tally the data at the end of the year and would perform causal studies to determine where the infections came from. The Administrator/DPCS was asked to provide an example of what corrective actions were implemented for the high cases of UTIs. The Administrator/DPCS stated they determined that the cause of UTI was mostly due to incontinence, so they encouraged the staff to provide caregiver education regarding continence care. When asked to present the documented evidence showing the specific actions done for each of the infections identified, the Administrator/DPCS was unable to do so. The Administrator/DPCS was also asked to explain the inconsistency of the total number of infections reported in the documents titled 2021 Infection Surveillance Totals and UTI Data Collection 2021. The Administrator/DPCS acknowledged that she miscalculated the data and did not capture the total number of UTIs when performing causal analysis.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the skilled professionals provided care and services in accordance with the POC for nine of 17 sampled patients (Patients 2, 3, 5, 9, 10, 11, 13, 14, and 17). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. 6a. Review of Patient 2's clinical record showed the SOC was 1/18/21. The clinical record showed the patient received home health services during the certification period from 3/14/22 to 5/12/22. On 5/10/22 at 1030 hours, a joint home visit was conducted with RN 3. During the home visit, RN 3 was observed performing wound care to Patient 2's left arm shunt. RN 3 was observed donning gloves, removed the old dressing, sprayed gauze with wound cleanser and applied gauze and tape to the left arm shunt. RN 3 stated after dialysis, the next day they changed the bandage. The POC, for the certification period from 3/14/22 to 5/12/22, failed to show a wound care treatment order for Patient 2's left arm shunt. Further review of the patient's clinical record failed to show the patient's left arm shunt was cleansed with wound cleanser. b. The POC, for the certification period from 3/14/22 to 5/12/22, showed the SN to perform wound care to the LLE trauma wound by cleansing with wound cleanser, apply skin prep to edges, cover with foam border dressing, 2-3 times a week, and as needed until healed. On 5/10/22 at 1030 hours, a joint home visit was conducted with RN 3. During the home visit, RN 3 was observed performing wound care to Patient 2's left lower extremity (LLE). RN 3 was observed donning gloves, removed the old dressing, sanitized hands before donning new gloves, sprayed gauze with wound cleanser, patted wound with gauze, covered wound with optiform adhesive foam wound dressing, removed gloves, and performed hygiene. RN 3 was not observed using the skin prep to the edges, as per POC. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Manager 2 and RN 1 were informed and acknowledged the findings. 7. Review of Patient 11's clinical record was initiated on 5/11/22. Patient 11's clinical record cited the SOC was 3/18/22. The clinical record showed the patient received home health services during the certification period from 3/18/22 to 5/16/22. Review of the SN note dated 4/13/22, showed clinician to assess skin for breakdown. Further review of the SN note showed pt had a bright red rash in gluteal cleft and instructed to keep pt dry and apply barrier cream. The POC, for the certification period 3/18/22 to 5/16/22, showed clinician to assess skin for breakdown. Further review of the POC failed to show documentation for the application of barrier cream. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Manager 2 and RN 1 were informed and acknowledged the findings. 8. Review of Patient 5's clinical record was initiated on 5/10/22. Patient 5's clinical record showed the SOC was 3/24/22. The clinical record showed the patient received home health services during the certification period from 3/24/22 to 5/22/22. The POC, for the certification period 3/18/22 to 5/16/22, showed the nutritional requirements included regular, no concentrated sweets, and a heart healthy diet. Review of the SN note dated 4/29, 5/3, and 5/6/22 showed Patient 5's diet was regular/ low salt. The clinical failed to ensure the documentation of Patient 5's diet was consistent with the POC. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Manager 2 and RN 1 were informed and acknowledged the findings. 9. Clinical record review for Patient 17 was initiated on 5/16/22. The clinical record showed the SOC was 1/5/19. The patient was certified for home health services during the certification periods from 6/23/21 to 8/21/21 and 8/22/21 to 10/20/21. The POC for the certification periods from 6/23/21 to 8/21/21 and 8/22/21 to 10/20/21, showed SN interventions included: - Clinician to assess skin for breakdown; - Clean Wound #8, left lower coccyx, with wound cleanser, pat dry with gauze, apply triad cream to wound bed, and cover with sacral optiform dressing 2-3x weekly, until healed. Review of the Recertification OASIS dated 6/22/21, showed Patient 17 had one stage 2 pressure injury. The Recertification OASIS cited the following wounds: - Wound #9, a stage 2 pressure wound on her left lower coccyx with an open wound bed with no drainage measured at 1cm x 1cm. - Wound #10, a stage 1 pressure wound, red area on right upper coccyx measured 2cm x 1.5cm. Further review of the clinical record failed to show documented evidence the physician was notified of the wounds. Review of the Wound Care Worksheet dated 6/29/21, showed the patient was assessed to have a wound to the coccyx: - Wound #9, a stage two pressure wound on her left lower coccyx which measures 1cm x 0.8 cm with a red wound bed, open with no drainage - Wound #10, appears to be bone and measures 2cm x 1.5 cm In addition, interventions performed included: - Cleaned wound #8 to the left lower coccyx with wound cleanser, pat dry with gauze, apply Triad cream to wound bed, and cover with a sacral optiform dressing 2-3x weekly until healed, but no triad cream or dressing were applied. Further review of the clinical failed to show documented evidence the physician was notified of the wounds. The note also failed to document an assessment of wound #8. Review of the SN Wound Care Note dated 7/13/21, cited the patient to have the following wounds: - Wound #9, stage 2 pressure wound, on left lower coccyx with a red wound bed which is currently closed with no drainage, measured 0.8cmx 0.6cm. - Wound #10, appears to be bone and measures 2cm x 1.5 cm In addition, interventions performed included: - Cleaned wound #8 to the left lower coccyx with wound cleanser, pat dry with gauze, apply Triad cream to wound bed, and cover with a sacral optiform dressing 2-3x weekly until healed, but no triad cream or dressing were applied. - No Triad required, covered with sacral dressing after cleaning with wound cleanser. Further review of the SN note showed the patient has no open wounds on her coccyx. The note also failed to show documented evidence an assessment of wound #8. Review of the SN Wound Care note dated 7/20/21, showed the following: - Wound #9, stage 2 pressure wound, on left lower coccyx with a red wound bed with no drainage, measured 0.5cmx 0.5cm. - Wound #10, appears to be bone and measures 2cm x 1.5 cm with mild redness and no open areas. In addition, interventions performed at this visit included: - Cleaned wound #8 to the left lower coccyx with wound cleanser, pat dry with gauze, apply Triad cream to wound bed, and cover with a sacral optiform dressing 2-3x weekly until healed, but no triad cream or dressing were applied. - Wound #9 is again open, measures 0.5cm x 0.5cm and has a red wound bed, with no drainage. SN does wound care once weekly, and caregiver does wound care twice weekly. Further review of the SN note failed to show documented evidence a physicians order for wound care of Wounds #9 and #10. The note also failed to document an assessment of wound #8. Review of the SN Wound Care note dated 7/27/21, showed the following: - Wound #9, stage 2 pressure wound, on left lower coccyx with a red wound bed, open with no drainage, measured 0.5cmx 0.5cm. - Wound #10, appears to be bone and measures 2cm x 1.5 cm with mild redness, with increased redness, but open areas. In addition, interventions performed included: - Cleaned wound #8 to the left lower coccyx with wound cleanser, pat dry with gauze, apply Triad cream to wound bed, and cover with a sacral optiform dressing 2-3x weekly until healed, but no triad cream or dressing were applied. - Wound #9 is again open, measures 0.5cm x 0.5cm and has a red wound bed, with no drainage, remains open - Wound #10 has increasing redness, but is not yet open. Wound #10 was cleaned with wound cleanser, Triad cream and optiform dressing was applied. Further review of the SN note failed to show documented evidence of a physicians order for wound care for Wounds #9 and #10. The note also failed to document an assessment of wound #8. Review of the SN Wound Care note dated 8/10/21, showed the following: - Wound #9, stage 2 pressure wound, on left lower coccyx with a red wound bed, closed, measured 0.5cmx 0.5cm. - Wound #10, stage 1, appears to be bone and measures 2cm x 1.5 cm with mild redness, with increased redness, appears to be near breakdown. In addition, interventions performed included: - Cleaned wound #8 to the left lower coccyx with wound cleanser, pat dry with gauze, apply Triad cream to wound bed, and cover with a sacral optiform dressing 2-3x weekly until healed, but no triad cream or dressing were applied. - Wound #9 remains closed and Wound #10 is increasingly red and appears close to breakdown. No dressing required on wound #9. Wound #10 was cleansed with wound cleanser, patted dry with gauze, Triad cream applied and covered with an Optiform dressing 2-3x weekly until healed. Further review of the SN note failed to show documented evidence of a physicians order for wound care for Wounds #9 and #10. The note also failed to document an assessment of wound #8. Review of the Recertification OASIS dated 8/17/21, showed Patient 17 had two stage 2 pressure injuries. The recertification OASIS showed the patient had the following wounds: - wound #9 stage 2 pressure wound on her left lower coccyx with a red wound bed which is closed, measured 0.5cmx 0.5cm. - wound #10 stage 2 pressure injury which has increased in size now measuring 4cm x 3cm with a small open area measured 1cmx 0.8cm with red/white wound bed and a scant amount of yellowish drainage. Review of the Patient Communication dated 8/18/21, showed patient now has an open wound on her right upper coccyx bony prominence and request for wound consult for evaluation. Further review of the communication note, showed no documented evidence of any additional physician’s orders. Review of the Wound Care Worksheet dated 8/24/21, showed the patient was assessed to have two wounds to the coccyx" - Wound #9, a stage two pressure wound on her left lower coccyx which measures 1.5cm x 1.5cm with a red wound bed with no drainage - Wound #10, a stage three pressure wound on right upper coccyx measuring 4 cmx 3 cm drainage. In addition, interventions performed included: - Cleaned wound #8 to the left lower coccyx with wound cleanser, pat dry with gauze, apply Triad cream to wound bed, and cover with a sacral optiform dressing 2-3x weekly until healed, but no triad cream or dressing were applied. - Both wounds were cleansed with wound cleanser, and left open to air until wound wound consultants arrive for wound evaluation. Review of the SN Wound Care note dated 8/26/22 showed the patient had two wounds on the coccyx identified as Wound #9 (left coccyx) and Wound #10 (right upper coccyx). In addition, the SN note showed the interventions performed were the following: - Clean wound #8, left lower coccyx, with wound cleanser, pat dry with gauze, apply Triad cream to wound bed, and cover with sacral optiform dressing 2-3x weekly until healed. - Both wounds were cleansed with wound cleanser and patted dry with gauze, Triad cream was applied to Wound #9 only and both wounds were covered with sacral optiform dressing. Further review of the clinical record failed to show documented evidence the physician wound care orders were obtained for Wound #9 and #10. Review of the physician order dated 9/6/21 showed for Wound #9 and #10, clean both wounds with wound cleanser, apply triad paste, to wound #9 and cover with sacral dressing, and apply medihoney to wound #10, covered with xeroform gauze and sacral dressing. On 5/18/22 at 0845, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the findings. 1. Review of the agency's P&P titled Care Planning Process (undated) showed the care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. Review of Patient 3's clinical record showed the SOC was 12/12/21. The clinical record showed the patient received home health services during the certification period from 2/10/22 to 4/10/22. The POC, for the certification period from 2/10/22 to 4/10/22, showed to cleanse the pleural catheter insertion site with alcohol pads three times, cover with sterile gauze dressings, and secure with a Tegaderm dressing. Review of the SN Wound Care notes dated 3/15/22 and 3/17/22, showed the SN performed a dressing change on the pleural catheter insertion site. The SN wrote she used Betadine swabs to clean the insertion site. Further review of Patient 3’s clinical record showed no documented evidence the physician ordered Betadine to clean the pleural catheter insertion site. On 5/18/22 at 0836 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the findings. 2. Review of Patient 9’s clinical record showed the SOC was 11/20/20. The clinical record showed the patient received home health services during the certification period from 3/15/22 to 5/13/22. The POC, for the certification period from 3/15/22 to 5/13/22, showed to notify the physician if the diastolic blood pressure was greater than 90 or less than 60. Review of the SNV with Aide Supervision notes dated 3/24/22 and 4/21/22, showed the patient’s BP was 104/56 and 116/58 respectively; however, there was no documented evidence showing the SN rechecked the patient’s blood pressure nor notified the physician of Patient 9’s blood pressure measurements. On 5/18/22 at 0911 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the findings. 3. Review of Patient 13’s clinical record was initiated on 5/12/22. Review of Patient 13’s clinical record showed the SOC was 8/15/21. The clinical record showed the patient received home health services during the certification period from 8/15/21 to 10/13/21. The POC, for the certification period from 8/15/21 to 10/13/21, showed to assess the patient’s weight log every visit, instruct the patient on daily weight self-monitoring program, and to log the weight. Review of Patient 13’s record showed the SN visited the patient’s home on 8/19, 8/23, 8/27, 9/3, and 10/7/21; however, the Skilled Nurse Visit forms showed no documented evidence of the patient’s weight nor the information showing whether the patient had lost, gained, or maintained the weight. Further review of Patient 13’s record showed no documented evidence the SN had assessed the patient’s weight every visit as per the POC. On 5/18/22 at 0935 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the findings. 4. Review of Patient 10's clinical record showed the SOC was 2/4/22. The clinical record showed the patient received home health services during the certification period from 4/5/22 to 6/3/22. The POC, for the certification period from 4/5/22 to 6/3/22, showed to notify the physician if the systolic blood pressure was greater than 160 or less than 90 and if the diastolic blood pressure was greater than 90 or less than 60. Review of the Skilled Nurse Visit notes dated 4/25/22, showed the patient’s BP was 160/100. Under Coordination Plan, the SN wrote the physician was contacted regarding the patient’s urine flow. Further review of Patient 10’s clinical record showed no documented evidence showing the SN rechecked the patient’s blood pressure nor notified the physician of Patient 10’s blood pressure measurements. On 5/18/22 at 0957 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 was informed of the findings. 5. Review of Patient 14's clinical record showed the SOC was 3/18/22. The clinical record showed the patient received home health services during the certification period from 3/18/22 to 5/16/22. The POC, for the certification period from 3/18/22 to 5/16/22, showed to notify the physician if the patient experienced a pain level that was not acceptable to the patient, pain level greater than 5/10, pain medications not effective, patient unable to tolerate pain medications, or pain affecting ability to perform patient’s normal activities. Review of the SN Wound Care note dated 4/7/21, showed the patient’s pain level was 6/10 with occasional flareups of 10/10. The SN documented the patient experienced pain interfering with the patient’s activity or movement “daily, but not constantly.” Further review of the clinical record showed no documented evidence the physician was notified of the patient’s pain. On 5/18/22 at 1100 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 was informed of the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for six of 17 sampled patients (Patients 2, 3, 6, 10, 12, and 14), creating the increased risk of substandard healthcare outcomes to these patients. 4. Review of Patient 2's clinical record was initiated on 5/10/22. The clinical record showed the SOC was 1/18/21. The patient was certified for home health services during the certification period from 3/14/22 to 5/12/22. a. The POC, for the certification period from 3/14/22 to 5/12/22, showed the to report to physician of unrelieved pain greater than 5 on 0-10 scale, and any other significant changes. The SN notes dated 3/15, 3/22, 3/26, 3/31, 4/5, 4/9. 4/12, 4/14, 4/16, 4/28, 4/30, and 5/5 showed Patient 2's pain intensity was not assessed. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and 3. Clinical Managers 2 and 3 were informed and acknowledged the findings. b. The POC, for the certification period from 3/14/22 to 5/12/22, showed nutritional requirements included no added salt, 2000 Calorie ADA (American Diabetes Association) diet, renal diet, no concentrated sweets, and heart healthy diet. SN notes dated 3/26/22 showed Patient 2 was on a fluid restriction and was instructed to drink as much as is allowed. SN notes dated 5/7/22 showed Patient 2 was on fluid restrictions for 32 ounces over 24 hours. Further review of Patient 2's clinical record, failed to show the information was reflected on the patient's POC. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and 3. Clinical Managers 2 and 3 were informed and acknowledged the findings. c. The POC, for the certification period from 3/14/22 to 5/12/22, showed the following SN interventions related to wound care: - SN to assess and when needed apply a new pressure dressing to the left arm; - Cleanse with wound cleanser, apply Calmoseptine ointment to the wound BID and as needed; SN every week for wound care and caregiver to apply daily and as needed; Further review of the POC failed to specify the wound site for this wound care treatment - SN to assess/ evaluate wound(s) at each dressing change and as needed for signs and symptoms of infection. Report to physician increased temperature greater than 100.5F, chills, increase in drainage, foul odor, redness, unrelieved pain greater than 5 on 0-10 pain scale, and any other significant findings. - SN to perform/ instruct the patient/ caregiver on wound care as follows: Left lower extremity (LLE) trauma wound and right lower extremity (RLE) trauma wound cleanse with wound cleanser apply skin prep to edges, cover with foam border dressing 2-3x a week and as needed until healed; - SN to perform wound care as follows: RLE cleanse with wound cleanser or normal sterile saline, apply skin prep to edges and cover with foam dressing 3x a week. Review of the SN notes dated 3/29, showed dressing/ wound care done to LLE per POC. Review of the SN notes dated 3/24/22 showed dressing to RLE changed per POC. LLE wound healed and open to air. However, further review of the SN note showed SN continued to performed wound care on LLE and RLE wounds. Review of the SN notes dated 3/29, 4/5, 4/7, and 4/16/22 showed SN performed wound care to LLE changed per POC. Further review of the SN note showed SN performed wound care on LLE and RLE wounds. Review of the SN note dated 4/14/22 showed SN performed wound care to the LLE wound per POC, and noted the RLE wound had healed. However, further review of the SN note showed SN performed wound care on LLE and RLE wounds. Review of the Wound Care Worksheet dated 4/2/22, showed a wound to the LLE identified as an abrasion (traumatic etiology), was healed. However, further review of the SN note showed the SN performed wound care on LLE and RLE wounds. Review of the Wound Care Worksheet dated 4/28/22, showed a wound to the LLE identified as an abrasion (traumatic etiology), was healed. However, further review of the SN note showed the SN performed wound care on LLE and measured the LLE wound. Review of Patient 2's clinical record failed to show consistent documentation of wound status and treatments performed. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and 3. Clinical Managers 2 and 3 were informed and acknowledged the findings. 5. Review of Patient 12's clinical record showed the SOC was 2/23/22. The clinical record showed the patient received home health services during the certification period 2/23/22 to 4/23/22. The POC, for the certification period from 2/23/22 to 4/23/22, showed the clinician to instruct the patient/ caregiver to contact agency to report any fall with or without minor injury and to call 911 for fall resulting serious injury. Review of the Patient Communication note dated 4/18/22, showed Patient 12's family reported Patient 12 lost his balance and fell. The note cited the patient had noticeable bruising to his left side, and notified the physician and supervisor. However, the note failed to show documented evidence of the physician's response. On 5/18/22 at 0959 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the finding. 6. Review of Patient 6's clinical record showed the SOC was 4/21/22. The clinical record showed the patient received home health services during the certification period 4/21/22 to 6/19/22 . The POC, for the certification period from4/21/22 to 6/19/22 , showed to notify the physician of: - Temperature greater than (>) 101 or less than () 90 or less than () 24 or less than () 160 or ness than () 90 or less than (<); - Oxygen saturation less than (<) 90%. However, further review of the POC failed to show the parameters were completed. On 5/18/22 at 0959 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the finding. 1a. Review of Patient 3's clinical record showed the SOC was 12/12/21. The clinical record showed the patient received home health services during the certification periods from 2/10/22 to 4/10/22 and 4/11/22 to 6/9/22. The POC, for the certification period from 2/10/22 to 4/10/22, showed Patient 3’s nutritional requirement was no added salt; however, review of the SN notes showed the SN was documenting the patient to have a low sodium diet which was inconsistent with the POC. b. The POC, for the certification period from 4/11/22 to 6/9/22, showed Patient 3’s nutritional requirement was no added salt and heart healthy; however, review of the SN notes showed the SN was documenting the patient to have a low sodium diet only, which was inconsistent with the POC. On 5/18/22 at 0830 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the findings. 2a. Review of Patient 10's clinical record showed the SOC was 2/4/22. The clinical record showed the patient received home health services during the certification periods from 2/4/22 to 4/4/22 and 4/5/22 to 6/3/22. The POC, for the certification period from 2/4/22 to 4/4/22, showed Patient 10’s nutritional requirements included NPO and Jevity 1.5 1440 cc/day; however, review of the SN notes showed the SN was documenting the patient to have a regular diet and Jevity 1.5 350 cc every four hours which was inconsistent with the POC. b. The POC, for the certification period from 2/4/22 to 4/4/22, cited SN visits 1W1, 1-2W4, then 1mo1 and 3 PRN for complications and change in condition. Review of the Physician Order dater 3/24/22, showed to continue CHHA visits 1-2W1 beginning on 3/27/22. Review of the HHA Visit notes dated 3/29/22, showed the CHHA visited the patient at home. The CHHA documented the patient had a rash between the buttocks which was washed and dried. The CHHA documented the family applied a rash cream as instructed by the RN. Review of the SNV with Aide Supervision notes dated 3/29/22, showed the SN visited the patient at home and conducted a CHHA supervisory visit. There was no documented evidence showing the RN had assessed Patient 10 to have a rash on the buttocks nor was there documentation showing the RN had instructed the family to apply a cream on the rash. c. The POC, for the certification period from 4/5/22 to 6/3/22, showed Patient 10’s nutritional requirements included NPO and Jevity 1.5 1440 cc/day; however, review of the SN notes showed the SN was documenting the patient to have a regular diet which was inconsistent with the POC. On 5/18/22 at 0957 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manger 2 and RN 1 verified the findings. 3. Review of Patient 14's clinical record showed the SOC was 3/18/21. The clinical record showed the patient received home health services during the certification period from 5/17/21 to 6/2/21. The POC, for the certification period from 5/17/21 to 6/2/21, showed Patient 10’s nutritional requirements included regular and full liquid four times per day; however, review of the SN notes showed the SN was documenting the patient to have a soft diet which was inconsistent with the POC. On 5/18/22 at 1100 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manger 2 and RN 1 verified the findings.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide at least 12 hours of in-service training during each 12-month period for one of two CHHAs (CHHA 1). This failure created the risk for the CHHA not receiving the updated information necessary to improve skills and provide competent care to vulnerable patients. On 5/16/22 at 1400 hours, an interview was conducted with the Administrator/DPCS regarding the required annual 12 hours in-service trainings provided to the agency’s CHHAs. The Administrator/DPCS stated the CHHA in-service trainings were provided monthly, beginning at the start of the calendar year. Review of CHHA 1’s employee file was initiated on 5/16/22. The employee file showed CHHA 1 had completed nine hours of in-service training for the year of 2021. There was no documented evidence CHHA 1 was provided with in-service trainings for the months of October, November, and December 2021. In addition, there was no documented evidence CHHA 1 had completed the required 12-hour in-service trainings for the year of 2020. On 5/18/22 at 1203 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written assignment for CHHA was prepared by the RN for one of 17 sampled patients (Patient 9). This failure created the risk of not providing the necessary care and services to this patient. Review of Patient 9's clinical record was initiated on 5/11/22. The clinical record showed the SOC was 11/20/20. The patient was certified for home health services during the certification periods from 1/14/22 to 3/14/22 and 3/15/22 to 5/13/22. The POC, for the certification periods from 1/14/22 to 3/14/22 and 3/15/22 to 5/13/22, cited CHHA visits 1W8. Further review of the clinical record failed to show documented evidence the CHHA Care Plans were prepared by the RN for the certification periods from 1/14/22 to 3/14/22 and 3/15/22 to 5/13/22. On 5/18/22 at 0925 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and verified the findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the CHHA failed to provide services as per the plan of care for one of 17 sampled patients (Patient 11), creating the risk of not providing the appropriate care and services to this patient. Review of the agency's P&P titled Home Health Aide Plan of Care (undated), showed the patient's Case Manager, upon initialization of aide services, will develop the home health aide place of care, consistent with the comprehensive plan of care and physician (or other authorized licensed independent practitioner) orders. a. Review of Patient 11's clinical record was initiated on 5/11/22. The clinical record showed the SOC was 3/18/22. The patient was certified for home health services during the certification period from 3/18/22 to 5/16/22. The POC, for the certification period from 3/18/22 to 5/16/22, cited CHHA visits 1-2W3 for safety with ADL care. Review of the CHHA Visit note dated 4/23/22, showed the CHHA applied hand rolls to prevent contractures to the hands. However, the POC did not include the instructions for the CHHA to apply hand rolls during the CHHA visits. Further review of the Aide Care Plan dated 4/8/22, did not include instructions for the CHHA to apply hand rolls during the CHHA visits. On 5/18/22 at 0822 hours, an interview with concurrent clinical record review was conducted with Clinical Managers 2 and 3. Clinical Managers 2 and 3 were informed and acknowledged the finding. b. Review of Patient 11's clinical record was initiated on 5/11/22. The clinical record showed the SOC was 3/18/22. The patient was certified for home health services during the certification period of 3/18/22 to 5/16/22. The POC, for the certification period from 3/18/22 to 5/16/22, cited CHHA visits 1-2W3 for safety with ADL care. Review of the Aide Care Plan dated 4/8/22, showed to record bowel movements at every CHHA visit. Review of the CHHA Visit notes dated 4/16/ 22, failed to include documentations as to whether Patient 11 had bowel movement. On 5/18/22 at 0822 hours, an interview with concurrent clinical record review was conducted with Clinical Managers 2 and 3. Clinical Managers 2 and 3 were informed and acknowledged the finding.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the CHHA reported the changes in the patient’s condition to the RN for two of 17 sampled patients (Patients 10 and 11). This failure created the risk of not providing the necessary care and services to the patient. 2. Review of Patient 11's clinical record showed the SOC was 3/18/22. The clinical record showed the patient received home health services during the certification period from 3/18/22 to 5/16/22. The POC, for the certification periods from 43/18/22 to 5/16/22 , cited HHA visits 1-2w3. Review of the HHA Visit notes dated 4/14, 4/23, and 4/30/22, showed the CHHA had documented Patient 11's complaints of pain to the right and left hands; however, there was no documented evidence showing the CHAA had reported to the RN regarding Patient 11's pain. On 5/18/22 at 0822 hours, an interview and concurrent clinical record review was conducted with Clinical Managers 2 and RN 1. Clinical Managers 2 and RN 1 were informed and acknowledged the findings. 1. Review of Patient 10's clinical record showed the SOC was 2/4/22. The clinical record showed the patient received home health services during the certification period from 4/5/22 to 6/3/22. The POC, for the certification period from 4/5/22 to 6/3/22, cited HHA visits 1-2W4. Review of the Aide Care Plan dated 4/4/22, showed to record the bowel movement every visit. Review of the HHA Visit notes dated 4/6, 4/9, 4/12, and 4/16/22, showed the CHHA had recorded the last bowel movement without any abnormalities. Review of the HHA Visit notes dated 4/20, 4/23, and 4/26/22, showed the CHHA documented the patient had loose bowel movements; however, there was no documented evidence showing the CHHA had reported to the RN regarding Patient 10’s loose bowel movements. On 5/18/22 at 0916 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the RN provided supervision to the CHHA no less than every 14 days for one of 17 patients (Patient 9). This failure created the risk of not providing safe and effective care to the patient. 1. Review of Patient 9's clinical record showed the SOC was 11/20/21. The clinical record showed the patient received home health services during the certification period from 1/4/22 to 3/14/22. The POC, for the certification period from 1/4/22 to 3/14/22, cited CHHA visits 1W8. Review of the Physician Order dated 1/14/22, showed to provide CHHA supervision visits every two weeks. Review of the SNV with Aide Supervision notes showed the RN visited the patient’s home on 1/25, 2/7, 2/21, 2/25, 3/1, and 3/11/22. However, there was no documented evidence the supervisory visits for the CHHA was conducted. The section used to document the evaluation of the CHHA was left blank. On 5/18/22 at 0923 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency's Administrator failed to ensure responsibility for the day-to-day operations of the agency as evidenced by: * The agency failed to ensure four of the eight employee files reviewed (CHHA 1, LVN 1, RNs 2, and 4) had the required TB screening and testing. * The agency failed to ensure the current certification for one of eight employee files reviewed (CHHA 2) was kept in the employee’s file. *The agency failed to ensure their P&P related to physical examination and TB screening was consistent with the state requirement. These failures created the risk of having unqualified staff provide care to the patients. 1. According to Title 22 74723 (c)(4), a written health assessment report shall provide for tuberculosis screening which shall be administered to all employees who have direct patient contact and annually thereafter, using a test for tuberculosis infection that is recommended by the CDC and licensed by the FDA. Review of the employee files conducted on 5/16/22 showed the following: * CHHA 1 was hired on 5/23/18. However, there was no documented evidence a TB testing or screening for the year 2020 was completed for CHHA 1. * LVN 1 was hired on 5/30/19. However, there was no documented evidence a TB testing or screening for the year 2021 was completed for LVN 1. * RN 2 was hired on 4/1/9. However, there was no documented evidence a TB testing or screening for the year 2021 was completed for RN 2. * RN 4 was hired on 6/26/19. However, there was no documented evidence a TB testing or screening for the years 2020 and 2021 was completed for RN 4. On 5/18/22 at 1203 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings. 2. Review of the agency's P&P titled Licensure/Certification/Registration (undated) showed a current copy or other proof of licensure, certification, and/or registration will be kept in the personnel file. Review of CHHA 2’s employee file was conducted on 5/16/22. CHHA 2 was hired on 12/27/16. The employee file showed a copy of another CHHA's certification verification. Further review of the employee file showed no documented evidence of CHHA 2’s current certification. On 5/18/22 at 1203 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the finding. 3. According to Title 22 74723 (b)(2) and (c)(4), a written health assessment of each employee who has direct patient contact shall be performed within six months prior to employment or within 15 days of assuming employment with the agency. The written health assessment report shall provide for tuberculosis screening which shall be administered to all employees who have direct patient contact and annually thereafter using a test for tuberculosis infection that is recommended by the CDC and licensed by the federal FDA. However, review of the agency’s P&P titled Selection/Hiring of Personnel (undated) showed a current physical and TB test/chest X-ray must be received prior to the first day of seeing patients for all clinical staff, which was inconsistent with Title 22 requirement. On 5/18/22 at 1400 hours, an interview and concurrent record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings.

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 provide services in accordance with the clinical practice guidelines and accepted professional standards of practice for four of 17 sampled patients (Patients 3, 8, 10, and 16). * The agency failed to ensure the CHHA visit note was completed in a timely manner for Patient 10. * The agency failed to ensure the RN performed the PICC line assessments for Patient 3. * The agency failed to perform wound assessments for Patients 8 and 16. These failures created the risk for not providing appropriate care to the patients. 1. Review of the document provided by the agency titled Paperwork Timelines (undated) showed all clinical documentation is to be completed within seven days of the visit or assigned date. Review of Patient 10's clinical record showed the SOC was 2/4/22. The clinical record showed the patient received home health services during the certification period from 4/5/22 to 6/3/22. The POC, for the certification period from 4/5/22 to 6/3/22, cited CHHA visits 1-2W4. Review of Patient 10’s clinical record showed the CHHA visited the patient’s home on 5/9/22. However, there was no documented evidence the CHHA had completed the visit notes. On 5/18/22 at 0916 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the findings. 2. Review of the agency's P&P titled Standards of Care and Practice (undated) showed the standards of care and practice guidelines will establish interventions that are to be implemented. Use of standards of care and practice will be evident in the documentation of visits and assessments, as well as in the care planning process. In addition to the P&P, the agency provided the Lippincott's Nursing Procedures (Eighth edition) which was the practice guidelines the agency implemented for dressing changes. The guideline showed the documentation should include the condition and length of the external catheter, the appearance of the site, and any reports of pain or tenderness. Review of Patient 3's clinical record was initiated on 5/9/22. The clinical record showed the SOC was 12/12/21. The patient was certified for home health services during the certification period from 4/11/22 to 6/9/22. The POC, for the certification period from 4/11/22 to 6/9/22, cited SN visits 1-2W9 and 3 PRN visits for changes in condition. The SN Interventions included to change the PICC line dressing weekly using sterile technique. Review of the SN notes showed the SN visited the patient’s home on 4/12, 4/19, 4/26, and 5/3/22. Under the Interventions Performed section, the SN documented the PICC line dressing changes were performed. However, there was no documented evidence the SN had assessed and measured the external length of the PICC line catheter. On 5/18/22 at 0838 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 verified the findings. 3. The agency provided the Lippincott's Nursing Procedures (Eighth edition) which was the practice guidelines the agency implemented for wound care. The guideline showed to document a complete skin assessment and interventions used to prevent pressure injuries and the patient's response to these interventions. If a pressure injury develops, document changes in the condition or size of the pressure injury and elevations of skin temperature. Also, document when the practitioner was notified of pertinent observations of abnormalities, interventions performed, and the patient's response to interventions. Review of Patient 8's clinical record was initiated on 5/11/22. The clinical record showed the SOC was 3/17/22. The patient was certified for home health services during the certification period from 3/17/22 to 5/15/22. Review of the SOC OASIS dated 3/17/22, showed Patient 8 had wounds to the right lateral neck and left upper quadrant of the abdomen. Review of the SN Wound Care notes dated 3/28/22, showed the SN had cleaned the wound. However, there was no documented evidence the complete assessment was performed. There was no documentation of the measurement and characteristics of the wound. On 5/18/22 at 0853 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. 4. Review of Patient 16's clinical record was initiated on 5/12/21. The clinical record showed the SOC was 3/18/12. The patient was certified for home health services during the certification period from 7/16/21 to 9/10/21. The POC, for the certification period from 7/16/21 to 9/10/21, showed to assess/evaluate the wounds at each dressing change and PRN for signs and symptoms of infection. Review of the OASIS Recertification dated 7/14/21, showed Patient 16 had the wounds to the right lower extremity and right upper arm. Review of the SN Wound Care notes, for the certification period from 7/16/22 to 9/10/22, showed the SN had performed the wound dressings changes during the SN visits. However, there was no documented evidence of the complete assessment of the wound performed. There was no documentation of the measurements and characteristics of the wounds. On 5/18/22 at 0950 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the completed discharge summary included the patients’ medications and vital signs at the time of discharge for three of 17 sampled patients (Patients 14, 16 and 17). This failure created the risk for the patients not receiving continuity in care and medical treatment. 3. Review of Patient 17's clinical record showed the SOC was 1/5/19. The clinical record showed the patient received home health services during the certification period from 8/22/21 to 10/20/21. Review of the Discharge OASIS dated 10/9/21, showed the SN completed the discharge assessment and summary; however, there was no documented evidence showing the patient’s medications at the time of discharge. On 5/18/22 at 0845 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 3. Clinical Manager 3 was informed and acknowledged the findings. 1. Review of Patient 14's clinical record showed the SOC was 3/18/21. The clinical record showed the patient received home health services during the certification period from 5/17/21 to 6/2/21. Review of the Discharge OASIS dated 6/2/21, showed the SN completed the discharge assessment and summary; however, there was no documented evidence showing the patient’s medications at the time of discharge. On 5/18/22 at 1100 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 2 and RN 1. Clinical Manager 2 and RN 1 verified the findings. 2. Review of Patient 16's clinical record showed the SOC was 3/18/21. The clinical record showed the patient received home health services during the certification period from 7/16/21 to 9/10/21. Review of the Discharge OASIS dated 9/10/21, showed the SN completed the discharge assessment and summary; however, there was no documented evidence showing the patient’s medications at the time of discharge. In addition, there was no documented evidence showing the SN assessed the patient’s vital signs at the time of discharge. On 5/18/22 at 0957 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings.