Every finding on record at Caring Angels Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 10/10/24. Standard level deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, it was determined that the Agency failed to review and update its Emergency Preparedness plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 10/8/24. The plan lacked a date indicating when it was last reviewed and updated. 2. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing 10/9/24 at 3:30 PM, the President and Assistant Administrator confirmed the Agency’s Emergency Preparedness plan lacked a date, indicating when the Plan was last reviewed and revised.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update the Emergency Preparedness policies, procedures, and risk assessment as required. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 10/8/24. The plan contained the Emergency Preparedness policies and procedures that lacked a date, indicating when the policies and procedures were last reviewed and updated. 2. The Agency’s risk assessment titled, "Analysis of Risk Assessment for Potential Disasters," was dated “7/21/2017”. The plan lacked documentation that the risk assessment was reviewed and updated every two years. 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 3:30 PM, the President and Assistant Administrator confirmed the Agency’s Emergency Preparedness plan lacked a date to indicate when the policies and procedures were last reviewed and revised, and confirmed the “7/21/2017" date on the risk assessment.

42 CFR 484.80(f)(3): Eligible training and competency evaluation organizations. Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.484.50 Patient Rights 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care 42 CFR 484.105 Organization and Administration of Services 42 CFR 484.110 Clinical Records Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months effective 10/10/24. This applies even if the agency is not currently conducting aide training and/or competency evaluation. Abbreviations: x = times # = number w/wk = week AM = morning > = greater than cm = centimeters SN = Skilled Nurse POC = Plan of care SOC = Start of care BP = Blood Pressure PsOC = Plans of Care lb./lbs = pound/pounds MD = Medical Doctor RN = Registered Nurse DM = Diabetes Mellitus PM = afternoon/evening Pt./ Pts. = Patient/Patients LPN = Licensed Practical Nurse PT = Physical Therapy/Therapist OASIS = Outcome and Assessment Information Set

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 a review of the Error Summary report and staff interview, it was determined that in 86 reports submitted for a 12-month period, the Agency failed to ensure OASIS assessments are submitted within 30 days of assessment. This has the potential effect to affect Agency quality measures. Findings include: 1. The Error Summary report for 07/2023 to 06/2024 (12 months) was reviewed on 10/7/24. The report included a warning for 86 of 165 (52.12 %) assessments with Error # -3330 Record submitted late, more than 30 days after completing the assessment. 2. During an interview with the Assistant Administrator 7/10/24 at 10:20 AM, the Assistant Administrator confirmed the Agency failed to submit OASIS reports in a timely manner, resulting in a warning.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, interview and observation during a home visit, and staff interview, it was determined that the Agency failed to ensure the Pt. receive information concerning Pt. rights during the initial visit; contact information of the Administrator was provided to Pts.; receive information regarding OASIS Privacy Rights, Pt. rights and responsibilities, Agency transfer and discharge policies, Agency policy concerning the complaint process, ensure the Pt./representative was informed in writing of the services to be provided and frequency of visits, clinical record information is maintained in a private and confident manner, provide State Hotline information to the Pt., and failed to provide information that no bias or prejudice will occur for verbalizing concerns regarding the Agency. Findings include: 1. In 1 of 3 home visits conducted, the Agency failed to ensure the Pt. receive information concerning Pt. rights during the initial visit (G412). 2. The Agency failed to ensure contact information of the Administrator was provided to Pts. (G414). 3. In 1 of 3 home visits conducted, the Agency failed to provide OASIS Privacy Rights (G416). 4. In 1 of 3 home visits conducted, the Agency failed to provide the Pt. information regarding Pt. rights and responsibilities (G418). 5. In 1 of 3 home visits conducted, the Agency failed to provide the Pt. written information regarding the Agency's policies on transfer and discharge (G422). 6. In 1 of 3 home visits conducted, the Agency failed to provide the Pt. written information regarding the Agency's policy concerning the complaint process (G432). 7. In 7 of 7 clinical records reviewed, the Agency failed to ensure the Pt./representative was informed in writing of the services to be provided and the frequency of visits (G434). 8. The Agency failed to ensure clinical record information is maintained in a private and confidential manner (G438). 9. In 1 of 3 home visits conducted, the Agency failed to provide State Hotline information to the Pt. (G444). 10. In 1 of 3 home visits conducted, the Agency failed to ensure the Pt. received information that no bias or prejudice will occur for verbalizing concerns regarding the Agency (G448). The cumulative effect of these systemic practices resulted in Agency's inability to inform the Pt. of their rights.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) 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. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, interview during a home visit, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to ensure the Pt. receive information concerning Pt. rights during the initial visit. Findings include: 1. The Agency's Pt. admission folder was reviewed on 10/7/24 at 1:00 PM, and contained documents pertaining to Pt. rights and responsibilities. 2. Pt. #2 was admitted to home health services on 7/2/24 with the primary diagnosis Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 to 4/Unspecified Chronic Kidney Disease. A home visit was conducted on 10/9/24 at 10:30 AM with the Backup Director of Nursing. During the home visit an interview was conducted with Pt. #2 and a family member. A request was made to review the Agency's Pt. admission folder. Pt. #2 and the family member stated the nurse did not provide a Pt. admission folder during the SOC visit on 7/2/24 or after SOC visit. Pt. #2's family member stated, "...I thought that was strange that the nurse did not leave anything..." As of 10/7/24, the Agency failed to provide Pt. #2 written information pertaining to Pt. rights and responsibilities. 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 3:30 PM, the Backup Director of Nursing confirmed the Agency failed to ensure Pt. #2 received information concerning Pt. rights, responsibilities.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation and interview during home visits, and staff interview, it was determined the Agency failed to provide the Pt./patient's representative information regarding the Administrator. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 10/7/24 at 1:00 PM. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 10/7/24, 10/8/24 and 10/9/24: Patient #1. SOC 9/3/24. Patient #2. SOC 7/2/24. Patient #3. SOC 9/19/24. During the home visits of Pts. #1, and #3, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. During an interview with Pt. #2, the Pt. stated an admission folder was not provided. 3. The following clinical records were reviewed on 10/8/24 to 10/9/24: Pt. #1. SOC 9/3/24. Pt. #2. SOC 7/2/24. Pt. #3. SOC 9/19/24. Pt. #4. SOC 2/6/24. Pt. #5. SOC 5/9/24. Pt. #6. SOC 12/5/23. Pt. #7. SOC 8/25/23. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During staff interviews with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 1:30 PM; the administrative team confirmed the Agency failed to provide the Pt./patient’s representative with the Administrator's name and contact information.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, interview during a home visit, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to provide OASIS Privacy Rights. Findings include: 1. The Agency's Pt. admission folder was reviewed on 10/7/24 at 1:00 PM, and included a document titled, "Home Health Agency Outcome and Assessment Information Set (OASIS) Statement of Patient Privacy Rights". 2. Pt. #2 was admitted to home health services on 7/2/24 with the primary diagnosis Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 to 4/Unspecified Chronic Kidney Disease. A home visit was conducted on 10/9/24 at 10:30 AM with the Backup Director of Nursing. During the home visit an interview was conducted with Pt. #2 and the caregiver. A request was made to review the Agency's Pt. admission folder. The Pt. and caregeiver stated the nurse did not provide a Pt. admission folder. As of 10/7/24, the Agency failed to provide any information pertaining to OASIS Statement of Patient Privacy Rights. During the interview, asked Pt. #2 whether she was aware or informed of Patient Privacy Rights, Pt. #2 responded "No". 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 3:30 PM; the Backup Director of Nursing confirmed the Agency failed to provide Pt. #2 information and/or documentation regarding OASIS Privacy Rights.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, interview during a home visit, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to provide the Pt. information regarding Pt. rights and responsibilities. Findings include: 1. The Agency's Pt. admission folder was reviewed on 10/7/24 at 1:00 PM, and included a document titled, "Section III Your Rights and Responsibilities As A Health Care Patient... You have the right to..." 2. Pt. #2 was admitted to home health services on 7/2/24 with the primary diagnosis Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 to 4/Unspecified Chronic Kidney Disease. The clinical record was reviewed on 10/9/24 at 9:30 AM. The clinical record contained a form titled, "Admission Consent" with a section that included "I acknowledge receipt of my rights and responsibility as a patient... and I understand them..." The Admission Consent form was signed by the Pt. and dated 7/2/24. However, during a home visit conducted on 10/9/24 at 10:30 AM with the Backup Director of Nursing. Pt. #2 and the caregiver stated the nurse did not provide a Pt. admission folder during the SOC visit on 7/2/24 or after. As of 10/9/24, the Agency failed to provide Pt. #2 the Pt. rights and responsibilities in writing. 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 3:30 PM, the Backup Director of Nursing confirmed the Agency failed to provide Pt. #2 written information regarding Pt. rights and responsibilities.

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 a review of the Agency's Pt. admission folder, interview during a home visit, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to provide the Pt. written information regarding the Agency's policies on transfer and discharge. Findings include: 1. The Agency's Pt. admission folder was reviewed on 10/7/24 at 1:00 PM, and included a document titled, "Discharge, Transfer, and..." This section provided the Pt. information regarding situations whereas a Pt. may be discharged from the Agency or transferred to another Agency. 2. Pt. #2 was admitted to home health services on 7/2/24 with the primary diagnosis Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 to 4/Unspecified Chronic Kidney Disease. A home visit was conducted on 10/9/24 at 10:30 AM with the Backup Director of Nursing. During an interview with Pt. #2 and the caregiver, both stated the nurse did not provide a Pt. admission folder. As of 10/9/24, the Agency failed to provide Pt. #2 with written policies regarding discharge and transfer from the Agency. 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 3:30 PM, the Backup Director of Nursing confirmed the Agency failed to provide the Pt. written information regarding the Agency's policies on transfer and discharge.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, interview during a home visit, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to provide the Pt. written information regarding the Agency's policy concerning the complaint process. Findings include: 1. The Agency's Pt. admission folder was reviewed on 10/7/24 at 1:00 PM, and included a section titled, "Problem Solving Procedure". This section contained the process for lodging a complaint to the Agency's Administrator. 2. Pt. #2 was admitted to home health services on 7/2/24 with the primary diagnosis Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 to 4/Unspecified Chronic Kidney Disease. A home visit was conducted on 10/9/24 at 10:30 AM with the Backup Director of Nursing. During an interview with Pt. #2 and the caregiver, both stated the nurse did not provide a Pt. admission folder, neither did the nurse explain how to file a complaint with the Agency. As of 10/9/24, the Agency failed to provide Pt. #2 with information for filing a complaint to the Agency's Administrator. 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 3:30 PM, the Backup Director of Nursing confirmed Agency failed to provide the Pt. information regarding the Agency's policy concerning the Agency's complaint process.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical record review, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure the Pt./representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1. The Pt. admission folder was reviewed on 10/7/24 at 1:00 PM. The folder contained the “Admission Consent” form that included a section titled "Consent for Treatment", requiring the SN to complete during the SOC visit and document the services to be provided and visit frequencies. 2. The following clinical records were reviewed on 10/8/24 to 10/9/24: Pt. #1. SOC 9/3/24. Pt. #2. SOC 7/2/24. Pt. #3. SOC 9/19/24. Pt. #4. SOC 2/6/24. Pt. #5. SOC 5/9/24. Pt. #6. SOC 12/5/23. Pt. #7. SOC 8/25/23. The clinical records contained an "Admission Consent" form signed by the Pt./representative. The consent forms lacked documentation of the service(s) to be provided and visit frequencies. 3. Home visits were conducted on the following Pts. on 10/7/24, 10/8/24 and 10/9/24: Pt. #1. SOC 9/3/24. Pt. #2. SOC 7/2/24. Pt. #3. SOC 9/19/24. During the home visits of Pts. #1 and 3, the Pt. admission folders were observed and lacked documentation indicating the Pt./representative was notified of the discipline(s) to provide service, and frequency of visits in writing. During the home visit with Pt. #2, an interview was conducted with Pt. #2 and the caregiver that stated the nurse did not give a Pt. admission folder to Pt. #2. 4. During staff interviews with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 1:30 PM, and 2:30 PM to 4:00 PM; the Assistant Administrator and Backup Director of Nursing confirmed the above findings.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation and staff interview, it was determined the Agency failed to ensure clinical record information is maintained in a private and confident manner. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 10/7/24 at 8:30 AM, arrived at the Agency's door, knocked and the door swung open. Spoke loudly identifying myself, there was no response. Observed the one room office suite with no person inside. Observed binders and papers on desks and shelving units, at 8:35 AM closed the door. Returned at 8:50 AM, again knocked on the Agency's suite door, and the door swung open, observed that no one was inside the Agency, closed the door. At 9:17 AM, returned to the Agency's suite and was greeted by the Agency's Assistant Administrator. 2. During the entrance interview with the Assistant Administrator on 10/7/24 at 9:47 AM, the Assistant Administrator stated he arrived at the Agency today at 9:03 AM. The Assistant Administrator stated, prior to 10/7/24, the last time anyone was in the office was Friday 10/4/24. The Assistant Administrator stated the individuals in the office on 10/4/24 were the President, Administrator, Assistant Administrator, the Alternate Director of Nursing, and Employee #5. 3. On 10/7/24 at 10:34 AM, a tour of the Agency's suite was conducted with the Assistant Administrator. Observed a chart review binder and OASIS reports binder with Pt. PsOC and Pt. identifiable information inside the binders. From 10/4/24 to 10/7/24, the Agency's Administrator failed to ensure Pt. protected information, including clinical record data was kept in a classified and secure method. 4. During an interview with the Assistant Administrator on 10/7/24 at 9:47 AM; and on 10/10/24 at 2:30 PM with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing; the Assistant Administrator confirmed the above findings.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on an interview during a home visit and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to provide State Hotline information to the Pt. Findings include: 1. Pt. #2 was admitted to home health services on 7/2/24 with the primary diagnosis Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 to 4/Unspecified Chronic Kidney Disease. A home visit was conducted on 10/9/24 at 10:30 AM with the Backup Director of Nursing. During the home visit, an interview was conducted with Pt. #2 and the caregiver that stated the nurse did not provide any instructions on filing a complaint with the State Hotline, verbally or in writing. 2. During an interview on 10/9/24 at 3:30 PM with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing; the Backup Director of Nursing confirmed Pt. #2 was not provided information regarding the State Hotline.

Freedom from discrimination or reprisal CFR(s): 484.50(c)(11) Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, interview during a home visit, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to ensure the Pt. receive information that no bias or prejudice will occur for verbalizing concerns regarding the Agency. Findings include: 1. The Agency's Pt. admission folder was reviewed on 10/7/24 at 1:00 PM, and contained several documents titled, "Problem Solving Procedure" and "Section III Your Rights and Responsibilities...Lodge complaints..." These sections provided Pt. information and instructions for filing a complaint and/or calling the Agency with a concern or complaint. 2. Pt. #2 was admitted to home health services on 7/2/24 with the primary diagnosis Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 to 4/Unspecified Chronic Kidney Disease. A home visit was conducted on 10/9/24 at 10:30 AM with the Backup Director of Nursing. During the home visit an interview was conducted with Pt. #2 and the caregiver. A request was made to review the Agency's Pt. admission folder. The Pt. and caregiver stated the nurse did not provide a Pt. admission folder, and the nurse did not state that Pt. #2 will not be discriminated for filing a complaint or addressing concerns regarding treatment and services provided by the Agency. 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 3:30 PM, the Backup Director of Nursing confirmed the Agency failed to provide Pt. #2 information (verbally and/or written that the Pt. will not experience bias or prejudice for verbalizing concerns regarding the Agency.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on review of clinical records, and staff interview, it was determined in 3 of 7 (Pts. #1, 3, and 5) clinical records reviewed, the Agency failed to ensure the initial assessment was done within 48 hours upon receipt of a referral. Findings include: 1. Pt. #1 was admitted to home health services on 9/3/24 with the diagnosis of Hemiplegia, Unspecified affecting Leg Non-Dominant Side. The clinical record was reviewed on 10/8/24. The record included the initial SOC assessment, dated 9/3/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 10/10/24, the record lacked a referral on or before 9/3/24 to initiate service. 2. Pt. #3 was admitted to home health services on 9/19/24 with the diagnosis of Other Specified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 10/8/24. The record included the initial SOC assessment, dated 9/19/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 10/10/24, the record lacked a referral on or before 9/19/24 to initiate service. 3. Pt. #5 was admitted to home health services on 5/9/24 with the diagnosis of Fibromyalgia. The clinical record was reviewed on 10/8/24. The record included the initial SOC assessment, dated 5/9/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 10/10/24, the record lacked a referral on or before 5/9/24 to initiate service. 4. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 1:30 PM; the administrative team was unable to confirm if the initial assessment was done within the time frame requirement.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on a review of clinical records, Agency policy, interviews, review of the Pt. admission folder, and home visit observation, it was determined the Agency failed to ensure the POC included interventions for wound care, staff provide treatment or service as ordered by the Physician, the RN assess the need for Pneumonia and/or Influenza vaccines of Pts., the SN notify the Physician of changes in a patients' condition, Agency staff educate and train the Pt., staff provide a calendar or schedule of projected visits, the SN provide the Pt. a list of their medications with instructions, and provide Pts. information regarding the Director of Nursing. Findings include: 1. In 1 of 1 clinical record reviewed of a Pt. that required wound care, the Agency failed to ensure the POC included interventions for wound care (G574). 2. In 4 of 7 clinical records reviewed, the Agency failed to ensure staff provide treatment or service, as ordered by the Physician (G580). 3. In 7 of 7 clinical records reviewed, the Agency failed to ensure the RN assess the need for Pneumonia and/or Influenza vaccines of Pts. (G582). 4. In 1 of 7 clinical records reviewed, the Agency failed to ensure the SN notify the Physician of changes in patients’ condition (G590). 5. In 1 of 3 home visits conducted, Agency staff failed to educate and train the Pt. (G610). 6. In 1 of 3 home visits conducted, the Agency failed to ensure staff provide a calendar or schedule of projected visits (G614). 7. In 1 of 3 home visits conducted, the Agency failed to ensure the SN provide the Pt. a list of their medications, and directions on administering the medications (G616). 8. In 7 of 7 clinical records reviewed, the Agency failed to provide information regarding the Director of Nursing (G622). The cumulative effect of these systemic practices resulted in the Agency's inability to provide care effectively and ensure Pts. received the care and services required on the POC.

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 review of a clinical record and staff interview, it was determined for 1 of 1 (Pt. #7) clinical record reviewed of a Pt. that required wound care, the Agency failed to ensure POC included interventions for wound care. Findings include: 1. Pt. #7 was admitted to home health services on 8/25/23 with the primary diagnosis Pressure Ulcer of Left Hip, Stage 2. The closed clinical record was reviewed on 10/9/24 at 7:30 AM. The closed clinical record contained the OASIS-E recertification form completed by the RN and dated 4/2/24. The recertification form included a "Wound Care Flowsheet" with documentation that Pt. #7 had a "left posterior ischium pressure ulcer...Length 2.5 cm... Width 2.5 cm... Depth 0.2 cm. Drainage Amount: Minimal... SN cleansed with saline, applied medihoney, covered with mepilex." As of 10/9/24, the POC for the certification period of 2/21/24 to 4/20/24 lacked interventions for wound care. 2. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 2:30 PM, the Alternate Director of Nursing stated the SN continued to provide weekly wound care, until the Agency discharged the Pt. on 3/26/24. During the same interview on 10/9/24, the Assistant Administrator and Alternate Director of Nursing confirmed the Agency failed to ensure the POC included interventions for wound care.

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 a review of clinical records and staff interview, it was determined that in 4 of 7 (Pts. #3, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure staff provide treatment or service, as ordered by the Physician. Findings include: 1. Pt. #3 was admitted to home health services on 9/19/24 with the diagnosis of Other Specified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 10/8/24 at 10:45 AM. The clinical record included a POC dated 9/19/24, that required SN services 1 time a week for 9 weeks and PT evaluation and treatment. The clinical record lacked the SN visit for week 2 (9/22/24 to 9/28/24) and the PT evaluation. 2. Pt. #5 was admitted to home health services on 5/9/24 with the diagnosis of Fibromyalgia. The clinical record was reviewed on 10/8/24 at 11:00 AM. The clinical record contained a POC dated 5/9/24, that required SN services 1 time a week for 9 weeks. The clinical record lacked documentation of notification of missed SN visits for 8/22/24, 8/29/24, 9/12/24, 9/19/24, and 9/26/24. 3. Pt. #6 was admitted to home health services on 12/5/23 with the primary diagnosis of Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/9/24 at 1:30 PM. The closed clinical record contained the POC for the certification period of 2/3/24 to 4/2/24 that required the SN "Notify Physician of... Blood Sugar, Fasting: Greater Than (>) 200 Less Than () 300 Less Than (the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 2:30 PM, the Alternate Director of Nursing stated the SN should have assessed Pt. #2's blood sugar. "If the Pt. had lost their machine (glucometer) then, the nurse should call the doctor and reorder another machine." It cannot be determined whether Pt. #2's blood sugar was within the parameters stated above. The POC effective 2/3/24 required, "Notify Physician of vital sign parameters out of range... Systolic BP: Greater Than (>) 160 Less Than () 90 Less Than (4. Pt. #7 was admitted to home health services on 8/25/23 with the primary diagnosis Pressure Ulcer of Left Hip, Stage 2. The closed clinical record was reviewed on 10/9/24 at 7:30 AM. The closed clinical record contained the POC for the certification period of 12/23/23 to 2/20/24 that required, "SN to continue perform wound care to left ischium: Cleanse with normal saline, pat dry, cover with Mepilex foam dressing using aseptic technique. Dressing changes every 7 days or as needed..." The SN visit notes dated 2/8/24 contained, "SN performed pressure ulcer care to left poster thigh, cleanse with wound cleanser, apply Medihoney, cover with island dressing..."; in a different section of the same SN visit note the SN documented, "SN cleanse wound with wound cleanser, pat dried with gauze, covered with bordered foam dressing..." The SN failed to provide wound care as indicated on the POC.The OASIS-E recertification assessment completed by the SN and dated 2/16/24 contained "SN cleansed with saline, applied medihoney, covered with mepilex” The SN failed to provide wound care as indicated on the POC. The POC for the certification period of 2/21/24 to 4/20/24 lacked instructions for the SN to provide wound care. However, the SN visit note dated 2/29/24 included, “SN provided wound care as listed on wound graph sheet.” The record lacked a wound graph sheet. It cannot be determined the wound care the SN provided on 2/29/24. 5. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 1:00 PM and 2:30 PM, the Assistant Administrator and Alternate Director of Nursing confirmed that staff failed to provide treatment or service as ordered by the Physician.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure the RN assess the need for Pneumonia and/or Influenza vaccines of Pts. Findings include: 1. The following clinical records were reviewed on 10/8/24 and 10/9/24: Pt. #1. SOC 9/3/24. Lacked an inquiry for the Pneumonia and Influenza vaccines. Pt. #2. SOC 7/2/24. Lacked an inquiry for the Pneumonia vaccine. Pt. #3. SOC 9/19/24. Lacked an inquiry for the Pneumonia and Influenza vaccines. Pt. #4. SOC 2/6/24. Lacked an inquiry for the Pneumonia and Influenza vaccines. Pt. #5. SOC 5/9/24. Lacked an inquiry for the Pneumonia and Influenza vaccines. Pt. #6. SOC 12/5/23. Lacked an inquiry for the Pneumonia and Influenza vaccines. Pt. #7. SOC 8/25/23. Lacked an inquiry for the Pneumonia and Influenza vaccines. 2. During the entrance interview on 10/7/24 at 9:50 AM, the Assistant Administrator stated, the RN is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information is documented in OASIS-E assessment form. During staff interviews with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 1:30 PM, and from 2:30 PM to 4:00 PM; the Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing confirmed the above findings.

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 a review of clinical records, Agency policy, and staff interviews, it was determined that in 1 of 7 (Pt. #6) clinical records reviewed, the Agency failed to ensure the SN notify the Physician of changes in patients’ condition. Findings include: 1. Pt. #6 was admitted to home health services on 12/5/23 with the primary diagnosis of Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/9/24 at 1:30 PM. The closed clinical record contained the OASIS-E SOC assessment form completed by the RN, and dated 12/5/23 that included the patient's weight as "200 lbs". The SN visit note dated 3/28/24 included "...pt. states that he is losing weight current weight is 136 lbs, nurse will weigh pt. weekly." The SN continue to provide service on 4/2/24, 4/16/24, 4/19/24, and 4/25/24, these visit notes lacked documentation that the SN weighed Pt. #6. The SN visit note dated 3/28/24 included Pt. #6's blood pressure as "177/96", the following week on 4/2/24 the patient's blood pressure was 106/58. The SN visit notes from 3/14/24 to 4/25/24 included documentation that Pt. #6 reported to the SN feelings of "fatigue, weakness, dyspnea, orthopnea, dizzy, and/or lightheadedness" The record lacked documentation that the Physician was notified of the 64 lb. weight loss within 3 1/2 months, fluctuation of the patient's blood pressure within a 5-day period, and/or other complaints verbalized by the Pt. The Agency’s "Transfer Summary " completed by the SN on 5/21/24 contained, "As per family, pt is not up to his baseline. he was not feeling well so family called 911 and took him to the hospital." The Agency's "Discharge Summary" completed by the SN on 5/22/24 contained, "Patient was transfer to in-patient facility for higher level of care due to change in condition. Patient passed away during hospitalization." 3. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 2:30 PM, the Assistant Administrator and the Alternate Director of Nursing confirmed that staff failed notify the Physician of changes in Pt. #6's condition.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of a clinical record, interview during a home visit, Agency policy review, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, Agency staff failed to educate and train the Pt. Findings include: 1. Pt. #2 was admitted to home health services on 7/2/24 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease or Unspecified Chronic Kidney Disease. The clinical record was reviewed on 10/9/24 at 9:30 AM. The clinical record included a POC dated 7/2/24 requiring ,"SN to provide...teaching/training... to properly assess, manage and mitigate pain... SN to instruct patient on disease process, including who to contact if signs and symptoms persist or worsen as well as dietary measures, medication management... SN to instruct patient/caregiver regarding self-management program for Dyspnea.., SN to instruct patient/caregiver regarding self-management of Osteoarthritis... PT Frequency: eval, treat" On 10/9/24 at 10:30 AM, a home visit was conducted with the Backup Director of Nursing. During the home visit an interview was conducted with the Pt. and caregiver. The Pt. stated, The nurse only takes her vital signs, "stayed 5 to 10 minutes," and leave. The Pt. and the caregiver stated, Pt. #2 did not receive any educational materials or information regarding the patient’s condition or care needs. The caregiver stated, "The nurse stays long enough to get her vitals and leave... the Physical Therapist is finished... No, he did not leave papers". A request was made to review the Pt. admission folder, the Pt. and caregiver stated the SN did not provide a folder. As of 10/9/24, the SN and PT failed to provide Pt. education and training materials pertaining to Pt. #2's diagnosis and treatment plan. 2. On 10/9/24, the Agency’s “Patient Education” policy was reviewed. The policy required, “Agency staff will provide initial and ongoing education to meet each patient’s needs.” 3. During an interview on 10/9/24 at 3:30 PM with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing; the Backup Director of Nursing confirmed Agency staff failed to educate and train the Pt.

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 review of the Agency's Pt. admission folder, clinical record, interview during a home visit, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to ensure staff provide a calendar or schedule of projected visits. Findings include: 1. The Agency's Pt. admission folder was reviewed on 10/7/24. The folder included a form titled "Employee Work Schedule Calendar (Projected Visit) with a section for all services provided by the Agency. Each discipline was required to document their proposed visits on the calendar (Sunday through Saturday). 2. Pt. #2 was admitted to the home health services on 07/2/24 with the diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 Chronic Lidney Disease or Unspecified Chronic Kidney Disease. The clinical record was reviewed on 10/9/24 at 9:30 AM. The clinical record included a POC dated 7/2/24 that required the SN and PT to provide service. A home visit was conducted on 10/9/24 with the Backup Director of Nursing. During the home visit, an interview was conducted with Pt. #2 and the caregiver. Pt. #2 stated a written visit schedule was not provided by the SN or PT. The caregiver stated, “she had 3 different therapist, the 1st two (2) were horrible, he said he would come on one day, but on that day sometimes he would show up and others he didn’t or was late." A request was made to review the Pt. admission folder, the Pt. and caregiver stated the Pt. did not receive a Pt. admission folder, that no documents were left with the Pt. during the SOC visit on 7/2/24 or after. 3. During an interview on 10/9/24 at 3:30 PM with the President, Administrator, Assistant Administrator, Assistant Director of Nursing, and the Backup Director of Nursing, the Backup Director of Nursing confirmed staff failed to provide Pt. #2 a calendar or schedule of projected visits.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on a review of clinical records, and staff interview, it was determined that in 1 of 3 (Pt. #2) home visits conducted, the Agency failed to ensure the SN provide the Pt. a list of their medications, and directions on administering the medications. Findings include: 1. Pt. #2 was admitted to the home health services on 07/2/24 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease or Unspecified Chronic Kidney Disease. The clinical record was reviewed on 10/9/24. The clinical record contained the "Medication Profile" form signed by the SN and last dated on 8/29/24. A home visit was conducted on 10/9/24 with the Backup Director of Nursing. During the home visit, an interview was conducted with Pt. #2 and the caregiver that stated the SN did not provide a Medication Profile, or any other list to contain the patient's medications. The Pt. stated the SN not had provided any instructions on administering the medications verbally or in writing. The caregiver stated, "The only list of the medications we have is the one the doctor printed out". A request was made to review the Pt. admission folder, the Pt. and caregiver stated the SN did not provide Pt. #2 with a Pt. admission folder. 2. During an interview with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24, the Backup Director of Nursing the Agency confirmed the SN failed to provide the Pt. a Medication Profile or a list of Pt. #2’s medications.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, clinical records, observation and interview during home visits, and staff interview, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide information regarding the Director of Nursing. Findings include: 1. The Pt. admission folder was reviewed on 10/7/24 at 1:00 PM. The folder lacked the name and information to contact the Director of Nursing. 2. The following clinical records were reviewed on 10/8/24 and 10/9/24: Pt. #1. SOC 9/3/24. Pt. #2. SOC 7/2/24. Pt. #3. SOC 9/19/24. Pt. #4. SOC 2/6/24. Pt. #5. SOC 5/9/24. Pt. #6. SOC 12/5/23. Pt. #7. SOC 8/25/23. The clinical records reviewed lacked the name and contact details of the Director of Nursing. 3. The following home visits were conducted on 10/7/24, 10/8/24 and 10/9/24: Pt. #1. SOC 913/24. Pt. #2. SOC 7/2/24. Pt. #3. SOC 9/19/24. During the home visits of Pts. #1 and 3, the Pt. admission folders were observed, and lacked the name and contact details of the Director of Nursing. During the home visit with Pt. #2 , the Pt. stated the SN did not provide an admission folder. 5. During staff interviews with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 at 1:30 PM, the Assistant Administrator and Backup Director of Nursing confirmed the Agency failed to provide information regarding the Director of Nursing.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on review of a clinical record, interview during a home visit, and staff interview, it was determined in 1 of 7 (Pt. #2) home visits conducted, the Agency failed to involve the Pt. in composing the POC. Findings include: 1. Pt. #2 was admitted to the home health services on 07/2/24 with the diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease or Unspecified Chronic Kidney Disease. The clinical record was reviewed on 10/9/24 at 9:30 AM. The clinical record included the POC for the certification period of 7/2/24 to 8/30/24, and the POC effective 8/31/24 required SN and/or PT services. On 10/9/24 a home visit was conducted with the Backup Director of Nursing. During the home visit, an interview was conducted with Pt. #2 and the caregiver, both stated the SN or PT did not involve them in Pt. #2's POC (frequency of visits, interventions, and goals). A request was made to review the Pt. admission folder, Pt. #2 and the caregiver stated Agency staff did not provide a folder or any documents. As of 10/9/24, Agency staff failed to involve the Pt./or caregiver with the establishment of Pt. #2's POC. 2. During an interview on 10/9/24 at 3:30 PM with the President, Administrator, Assistant Administrator, Assistant Director of Nursing, and the Backup Director of Nursing; the Backup Director of Nursing confirmed the Agency failed to involve the Pt. in composing the POC.

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 a review of clinical records, Agency policy, and staff interview, it was determined that for 1 of 5 (Pt. #6) clinical records reviewed wherein services were provided by a LPN, the Agency failed to ensure the RN conducted supervisory visits of the LPN once a month, as required by the Agency. Findings include: 1. Pt. #6 was admitted to home health services on 12/5/23 with the primary diagnosis of Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/9/24 at 1:30 PM. The closed clinical record contained the LPN visit notes dated 3/7/24, 3/14/24, 3/21/24 and 3/28/24. As of 10/9/24, the record lacked documentation that the RN provided LPN supervision during the month of March 2024. 2. The Agency policy titled, "Supervision and Assignment of LPN's, Social Work and Therapy Assistants was reviewed and required, "...5...After assigning the LPN... Supervised home visits will be made by the professional according to client's needs, but at least once every month..." 3. During an interview on 10/9/24 at 3:30 PM with the President, Administrator, Assistant Administrator, Assistant Director of Nursing, and the Backup Director of Nursing; the Assistant Administrator confirmed the RN failed to supervise the LPN once a month.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, staff interview, contract review, Agency policy review, and clinical record review, it was determined the Agency failed to ensure the Administrator maintained responsibility for daily operations of the Agency; ensure the Clinical Manager/Director of Nursing, or an alternate was available during working hours of the Agency; and that at least one service was provided by direct staff. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency failed to ensure the Administrator maintained responsibility for daily operations of the Agency (G948). 2. The Agency failed to ensure the Clinical Manager/Director of Nursing, or an alternate was available during working hours of the Agency (G950). 3. In 2 of 7 clinical records reviewed, the Agency failed to ensure at least one service was provided by direct staff.(G982). The cumulative effect of these systemic practices resulted in the Agency's inability to provide appropriate clinical direction, and oversignt of Pt. care and services.

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 observation, Agency policy review, and staff interview, it was determined the Agency failed to ensure the Administrator maintained responsibility for daily operations of the Agency. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 10/7/24 at 8:30 AM, arrived at the Agency's door, knocked and the door swung open, identified myself, there was no response. Observed the office with no one inside. Observed binders and papers on desks and shelving units, at 8:35 AM closed the door. Returned at 8:50 AM, again knocked on the Agency's suite door, and the door swung open, observed that no one was inside the Agency, closed the door. At 9:17 AM, returned to the Agency's suite and was greeted by the Agency's Assistant Administrator. 2. During the entrance interview with the Assistant Administrator on 10/7/24 at 9:47 AM, the Assistant Administrator stated he arrived at the Agency today at 9:03 AM. The Assistant Administrator stated, prior to 10/7/24, the last time anyone was in the office was Friday 10/4/24. The Assistant Administrator stated the Agency staff were in the office on 10/4/24. 3. On 10/7/24 at 10:34 AM, a tour of the Agency's suite and an interview was conducted with the Assistant Administrator. Observed personnel records in an unlocked cabinet. During the interview, the Assistant Administrator stated the location of the personnel records is where they are usually kept. Observed a chart review binder and OASIS reports binder with Pt. PsOC and Pt. identifiable information inside the binders. The Agency's Administrator failed to ensure personnel and Pt. information was securely stored and maintained. 4. The written contractual agreement titled, ".... Service Level Agreement" lacked the effective date of the contract and the names of the authorizing individuals for this contract. The written contractual agreement included the definition of "Home Health Services means a Professional's provision of skilled nursing services to an Organization's Client". The written agreement lacked language indicating that all services provided will be monitored and controlled by the Agency, and it cannot be determined the length of time that the Agency had used contract nurses to provide SN services. 5. During an interview with the Assistant Administrator on 10/7/24 at 9:47 AM; and on 10/10/24 at 2:30 PM with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing; the Assistant Administrator confirmed the above findings.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on staff interviews, observation in the Agency’s suite, contract review, and Agency policy review, it was determined that the Agency failed to ensure the Clinical Manager/Director of Nursing, or an alternate was available during working hours of the Agency. This has the potential to affect all services provided by the Agency. Findings include: 1. On 10/7/24 at 9:47 AM, the entrance interview was conducted with the Assistant Administrator that stated the Agency's operation hours are Monday through Friday from 9:00 AM to 5:00 PM with on-call availability after hours. The Assistant Administrator stated the Director of Nursing (Clinical Manager) is a direct employee, but would not be available during the survey, but the Agency had an Alternate Director of Nursing (Employee #2) that would be available. 2. On 10/7/24 from 9:17 AM to 4:45 PM, observed that the Alternate Director of Nursing or a RN did not arrive at the Agency, and was not available for clinical supervision of Agency staff. 3. On 10/8/24 at 9:05 AM, an interview was conducted with the Assistant Administrator that stated Employee #2 was not available during the Agency's operation hours on 10/7/24. At 11:30 AM, the Agency's President and the "Backup Director of Nursing" (Employee #10) entered the Agency. An interview was conducted with the Backup Director of Nursing and Assistant Administrator, both stated the Backup Director of Nursing was hired as a consultant and contracted employee.. 4. On 10/8/24, the Assistant Administrator presented the "Backup Director of Nursing Contract" effective 10/4/24 for Employee #10. The contract included the job title of "Consultant/ Backup DON"(Director of Nursing). On 10/7/24, the Alternate Director of Nursing (Employee #2) and Backup Director of Nursing (Employee #10) were not available for supervision of clinical staff. 5. The Agency's policy titled "Supervision of Staff " was reviewed on 10/9/24 and contained, "...Responsibilities 1. The skilled nursing and other therapeutic services furnished will be under the supervision and direction of a physician or RN...2. The Director of Clinical Services... or Nursing Supervisor... Is available at all times during the operating hours..." 6. During an interview on 10/10/24 at 2:30 PM with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing, the Assistant Administrator confirmed the Agency lacked clinical supervision during all operating hours of the Agency.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on staff interview and Agency policy review, it was determined that in 2 of 7 (Pts. #6 and 7) clinical records reviewed, the Agency failed to ensure at least one service was provided by direct staff. Findings include: 1. On 10/9/24 at 2:30 PM, an interview was conducted with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Assistant Administrator. During the interview, the Assistant Administrator stated the Agency entered into a contract for routine SN services. 2. Pt. #6 was admitted to home health services on 12/5/23 with the primary diagnosis Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/9/24 at 1:30 PM. The clinical record contained the OASIS-E recertification form dated 4/2/14, and the SN visit note dated 4/16/24, both visits were conducted by a contract RN. 3. Pt. #7 was admitted to home health services on 8/23/23 with the primary diagnosis of Pressure Ulcer of Left Hip, Stage 2. The closed clinical record was reviewed on 10/9/24. The clinical record contained the SN visit notes dated 2/8/24, 2/22/24, 2/29/24, 3/7/24, 3/14/24, 3/21/24; and the OASIS-E recertification form dated 2/16/24, all visits ere conducted by a contract RN. 4. The Agency's policy titled, "Organization and Services Administration" was reviewed on 10/10/24. The policy contained "...2. All services not furnished directly... are monitored and controlled by the parent Agency..." 5. An interview was conducted with the Assistant Administrator on 10/8/24 at 2:40 PM, the Assistant Administrator stated it had been 2 years or more the Agency last provided Home Health Aide (a direct) service, Physical Therapy services are provided by direct and contract staff; Occupational Therapy and Speech Therapy services are contracted, and were last provided 2 or more years ago; and that Medical Social Worker service is contracted, last provided 2 or more years ago. 6. During an interview on 10/10/24 at 2:30 PM with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing; the Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing confirmed the use of contract nurses, Physical Therapists, Occupational Therapists, Speech Therapists, and Medical Social Workers. The Assistant Administrator and Backup Director of Nursing stated the Agency did not seek approval from the Illinois Department of Public Health, prior to using the contract nurses. During the same interview, the Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing confirmed the above findings.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on a review of clinical records, Agency policy, observation and staff interview, it was determined that the Agency failed to ensure the Physician was sent a copy of the transfer and/or discharge summary, that documentation entered into the clinical record was complete, and corrected as required by the Agency, and clinical records are protected and maintained in a confidential manner. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. In 1 of 2 closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the transfer and/or discharge summary (G1022). 2. In 3 of 7 clinical records reviewed, the Agency failed to ensure that documentation entered into the clinical record was complete, and corrected as required by the Agency (G1024). 3. The Agency failed to ensure clinical records are protected and maintained in a confidential manner (G1028). The cumulative effect of these systemic practices resulted in the Agency's inability to provide reports to the Physician; maintain complete and authenticated clinical records.

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 a review of clinical records, and staff interview, it was determined that in 1 of 2 (Pt. #6) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the transfer and/or discharge summary. Findings include: 1. Pt. #6 was admitted to home health services on 12/5/23 with the primary diagnosis Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/9/24 1:30 PM. The closed clinical record contained a Transfer summary completed by the RN on 5/21/24, and a Discharge Summary completed by the RN on 5/22/24. The record lacked documentation that a copy of either summary was sent to the Physician. 2. During an interview on 10/10/24 at 2:30 PM with the President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing; the Assistant Administrator confirmed the Agency failed to send a copy of the Transfer summary and/or Discharge Summary to the Physician.

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 a review of clinical records, Agency policy, and staff interview, it was determined in 3 of 7 (Pts. #2, 6 and 7) clinical records reviewed, the Agency failed to ensure that documentation entered into the clinical record was complete, and corrected as required by the Agency. Findings include: 1. Pt. #2 was admitted to the home health services on 07/2/24 with the diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease or Unspecified Chronic Kidney Disease. The clinical record was reviewed on 10/9/24 at 9:30 AM. The clinical record contained the form titled, "Beneficiary Elected Transfer" dated 7/2/24, signed by the SN, Assistant Administrator, and the Pt. The form lacked the name of the Agency that "will no longer provide Medicare covered home health services", as required by the Agency's form. 2. Pt. #6 was admitted to home health services on 12/5/23 with the primary diagnosis of Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/9/24 at 1:30 PM. The closed clinical record contained the form titled, "Beneficiary Elected Transfer" signed by the SN, Assistant Administrator, and the Pt. The form lacked the name of the Agency that "will no longer provide Medicare covered home health services". The form had a date that was scratched-out in 3 of 3 sections on the form requiring a date, and "12/05/23" was written over the scratched section. The closed record contained the form titled "Consent To Use And Disclose Health Information" signed by the Pt. The form had a date scratched-out and the date "12/08/23" written on the form. 3. Pt. #7 was admitted to home health services on 8/25/23 with the primary diagnosis Pressure Ulcer of Left Hip, Stage 2. The closed clinical record was reviewed on 10/9/24 at 7:30 AM. The closed clinical record contained weekly SN visit notes dated 2/29/24, 3/7/24, 3/14/24, and 3/21/24 which lacked a description of the Pressure Ulcer of the Left Hip. The closed record contained the form titled, "Beneficiary Elected Transfer" signed by the SN, Assistant Administrator, and the Pt. The form lacked the name of the Agency that "will no longer provide Medicare covered home health services". The form had the last digit of the year scratched-out in 2 of 3 sections that required a date to be entered. 4. The Agency policy titled "Client Care Records" was reviewed on 10/10/24 and required, "...It is crucial that accurate and complete client care records be maintained..." 5. The Agency policy titled "Correction Procedures" was reviewed on 10/10/24 and required, "Correction of entries must be made by the person who recorded the entry being corrected. Correction procedures are as follows: 1. Draw a single line throug the incorrect entry (ies). 2. Write correction(s). 3. Sign correction(s) by initial/signature. Include date in (and) time..." 6. The Agency policy titled "Wound Care Policy" was reviewed on 10/10/24 and required, "... Ongoing Wound Care Documentation... Wound Health Progress: Track changes in wound size, appearance, and drainage over time..." 7. During an interview with President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing on 10/9/24 from 2:30 PM to 4:00 PM, the Alternate Director of Nursing stated the SN is required to document a description of each wound, including measurements of the wound "once a week". During the same interview, the above findings were confirmed with the Assistant Administrator and the Alternate Director of Nursing.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, Agency policy review, and staff interview, it was determined the Agency failed to ensure clinical records are protected and maintained in a confidential manner. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 10/7/24 at 8:30 AM, arrived at the Agency's door, knocked and the door swung open. Observed the office suite with no individual inside. Observed binders and papers on desks and shelving units. Returned to the Agency's suite at 8:50 AM, again knocked on the Agency's suite door, and the door swung open, no person inside the Agency. At 9:17 AM, returned to the Agency's suite and was greeted by the Assistant Administrator. 2. During the entrance interview with the Assistant Administrator on 10/7/24 at 9:47 AM, the Assistant Administrator stated he arrived at 9:03 AM at the Agency. Inquired when the last time someone was inside the Agency prior to today. The Assistant Administrator responded, last Friday (10/4/24). 3. On 10/7/24 at 10:34 AM, a tour of the Agency was conducted with the Assistant Administrator. Observed on an open shelving unit, a chart review binder and OASIS reports binder with Pt. PsOC and Pt. identifiable information inside the binders. From 10/4/24 to 10/7/24, the Pt. clinical records were left unsecured and not maintained in a confidential manner. 4. The Agency's policy titled, "Patient Record: Protection and Retention" was reviewed on 10/10/24 and required, "...Central Record... stored in locked files in the office... Policy... 2. Each patient admitted to service has a record that contains documentation of the care provided and the physician's plan of treatment authorizing that care, as well as financial and billing information... 4. Every effort is made to protect records from being... stolen, or lost..." 5. During an interview with the Assistant Administrator on 10/7/24 at 9:47 AM; and on 10/10/24 at 2:30 PM with President, Administrator, Assistant Administrator, Alternate Director of Nursing, and the Backup Director of Nursing; the Assistant Administrator confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Disaster Plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness Plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's “Emergency Preparedness Disaster Plan” was reviewed on 8/23/21 at 11:45 AM. The Plan included documentation the Agency last reviewed and updated the Plan in "2017". As of 8/23/21, the Agency failed to review and revise the Plan every 2 years. 2. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 10:35 AM, both confirmed the above finding.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Disaster Plan and staff interview, it was determined the Agency failed ensure the risk assessment was reviewed and updated. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's “Emergency Preparedness Disaster Plan” was reviewed on 8/23/21 at 11:45 AM. The Plan included the document titled: “Analysis of Risk Assessment For Potential Disasters”. The form was dated “7/21/2017” and rated an “Epidemic” as “Low Risk Level”. The form was not updated to include pandemic or emerging infectious diseases. 2. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 10:35 AM, both confirmed the above finding.

Development of Communication Plan CFR(s): 484.102(c) (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). This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Disaster Plan and staff interview, it was determined the Agency failed to review and update the Communication Plan biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Disaster Plan was reviewed on 8/23/21 at 11:45 AM. The Plan included the “Communication Plan” which included documentation the Agency last reviewed and updated the Plan on "9/6/2018". As of 8/23/21, the Agency failed to review and revise the plan every 2 years. 2. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 10:35 AM, both confirmed the above finding.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, 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 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 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. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Plan, staff in-service binders and staff interview, it was determined the Agency failed to conduct Emergency Preparedness testing exercises. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. The Agency's “Emergency Preparedness Disaster Plan” dated “2017” was reviewed on 8/23/21 at 11:45 AM. The Plan lacked documentation the Agency conducted any testing of its Emergency Preparedness Plan. 2. The Agency's staff "In-service" binders for 2019, 2020 and 2021 was reviewed on 8/23/21 at 10:05 AM. The binders lacked documentation the Agency conducted any testing exercises. 3. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 10:35 AM, both confirmed the Agency failed to conduct any Emergency Preparedness testing exercises.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: W/Wk = Week # = Number E = Employee AM = Morning Eval = Evaluation SOC = Start of Care SN = Skilled Nurse RN = Registered Nurse hha = Home Health Aide Pt./Pts. = Patient/Patients PM = Afternoon, Evening APN = Advanced Practice Nurse PTA = Physical Therapy Assistant COVID-19 = Coronavirus Disease 2019 POC/PsOC = Plan of Care/Plans of Care PT = Physical Therapy/Physical Therapist

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service/treatment as ordered by the Physician, and indicated in the POC. This was found in 3 of 7 (Pts. #2, 4 and 3) clinical records reviewed. Findings include: 3. Pt. #3. SOC 2/5/21. Principal Diagnosis: Systemic Lupus Erythematosus. The clinical record was reviewed on 8/24/21 at 9:30 AM. The record included a POC for the certification period of 6/5/21 to 8/3/21 requiring, "Orders for Discipline and Treatment: SN 1 WK 9…” The record lacked documentation the SN provided a skilled visit for the week of 6/27/21 to 7/3/21. 4. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 11:00 AM and 1:30 PM, the above findings were confirmed. 1. Pt. #2. SOC 7/22/21. Primary Diagnosis: Unspecified Systolic (Congestive) Heart Failure. The clinical record was reviewed on 8/23/21 at 4:00 PM. The record contained the POC effective 7/22/21 requiring “PT EVAL AND TREAT”. The “PT Plan of Care dated 7/23/21 included “PT Frequency & Duration 2W5 1W1”. The record lacked documentation the PT provided any service after 7/28/21. 2. Pt. #4. SOC 7/7/21. Diagnoses: Essential (Primary) Hypertension, Unspecified Cerebral Infarction and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 8/23/21 at 4:30 PM. The record contained the POC effective 7/7/21 requiring hha service “2 WK 7”. The record lacked documentation the hha provided a second visit during the week of 8/1/21 to 8/7/21.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the POC contained the required elements. This was found in 2 of 7 (Pts. #4 and 7) clinical records reviewed. Findings include: 2. Pt. #7 SOC 1/14/21. Diagnoses: Chronic Obstructive Pulmonary Disease and Essential Hypertension. The clinical record was reviewed on 8/24/21 at 11:37AM. The POC for the certification period of 1/14/21 to 3/14/21 requires, "obtain oxygen saturation as needed and for shortness of breath...assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function...SN to instruct patient...including who to contact if signs and symptoms persist..." but lacked the parameters for reporting the oxygen saturation and vital signs results to the physician. 3. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 11:00 AM and 1:30 PM, the above findings were confirmed. 1. Pt. #4. SOC 7/7/21. Diagnoses: Essential (Primary) Hypertension and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 8/23/21 at 4:30 PM. The record contained the POC effective 7/7/21 and included: “…Gastrostomy Tube… preparation of tube feedings…” The POC lacked the name, amount and frequency of the tube feeding; and the amount and frequency of the water flushes.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, staff interview and Agency policy review, it was determined the Agency failed to assess patients' Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency. This was found in 3 of 7 (Pts. #2, 5 and 7) clinical records reviewed. Findings include: 3. Pt. #5. SOC 9/30/20. Principal Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 8/24/21 at 10:30 AM. The record contained a “Flu/Pneumonia Vaccine” form dated 9/30/20 that included the following documentation: “Are you interested in receiving the influenza vaccine? No… Are you interested in receiving the pneumonia vaccine? No” The form lacked the reason why the Pt. declined receiving the influenza and pneumonia vaccines. 4. Pt. #7. SOC 1/14/21. Principal Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 8/24/21 at 11:40 AM. The record contained a “Flu/Pneumonia Vaccine” form dated 1/14/21. The form included the following documentation: “Are you interested in receiving the influenza vaccine? Yes…. Are you interested in receiving the pneumonia vaccine? Yes. If the answer is Yes, please choose one of the following implementations.” The form lacked entries as to what action was implemented. 5. The Agency policy on “Vaccinations” was reviewed on 8/25/21 at 9:45 AM. The policy required, “1. Influenza: a. The Agency shall annually administer or arrange for administration a vaccination against influenza to each patient client… 2. Pneumococcal Pneumonia: a. The Agency shall administer or arrange for administration of a pneumococcal pneumonia… The following shall be considered to be documentation approaches that meet the requirements… (1) Individual patient/client record entries identifying the assessment for the need of vaccination, date of offer or referral, patient/client response, administration, contraindication, or refusal and any follow-up activities…(2) Standardized check-off form recording patient/client specific information, including the assessment for the need of vaccination, date of offer or referral, patient/client response, administration, contraindication or refusal, and any follow up activities. 6. During an interview with the Assistant Administrator and Director of Nursing on 8/23/21 at 11:00AM and 1:30 PM, the above findings were confirmed. 1. Pt. #2. SOC 7/22/21. Primary Diagnosis: Unspecified Systolic (Congestive) Heart Failure. The clinical record was reviewed on 8/23/21 at 4:00 PM. The record contained the “Flu / Pneumonia Vaccine” inquiry form signed by the SN and dated 7/22/21. The form lacked an inquiry regarding the patient’s Flu (Influenza) vaccine status. 2. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 11:00 AM, the Director of Nursing stated: “The inquiry (Flu and Pneumonia) is done at the SOC, it’s documented on the vaccine form and placed in the clinical record.”

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: A. Based on a review of the Agency’s Infection Control plan, clinical records and staff interview, it was determined the Agency failed to develop a COVID-19 screening process for field staff, office staff, visitors; and ensure staff screen Pts. for COVID-19 prior to providing Pt. service. This has the potential to affect all Pts. receiving service from the Agency, and was found in 4 of 7 (Pts. #1, 4, 3 and 5) clinical records reviewed. Findings include: 1. The Agency’s “Infection Control” plan was reviewed on 8/23/21 at 2:00 PM. The plan lacked a policy or procedure pertaining to screening for COVID-19 of the Agency’s staff and visitors. 2. Pt. 1. SOC 4/30/21. Primary Diagnosis: Type 2 Diabetes with Diabetic Autonomic (Poly) Neuropathy. The clinical record was reviewed on 8/23/21 at 3:10 PM. The record included the hha visit notes for 2 times a week from 7/27/21 to 8/13/21. The record lacked documentation the hha screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. 3. Pt. #4. SOC 7/7/21. Diagnoses: Essential (Primary) Hypertension and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 8/23/21 at 4:30 PM. The record contained hha visit notes dated 7/15/21, 7/19/21, 7/31/21 and 8/3/21. The record lacked documentation the hha screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. 4. During an interview with the Director of Nursing on 8/23/21 at 2:30 PM, the Director of Nursing stated “We do not screen ourselves, we need to develop something.” As of 8/23/21, the Agency lacked a policy and procedure that staff and visitors are screened for COVID-19, prior to reporting to work or engaging with visitors. 5. Pt. #3. SOC 2/5/21. Principal Diagnosis: Systemic Lupus Erythematosus. The clinical record was reviewed on 8/24/21 at 9:30 AM. The record included "HHA visit" notes for services provided on 6/29/21, 7/1/21, 7/6/21, 7/8/21, 7/13/21, 7/15/21, 7/20/21, 7/22/21, 7/27/21, 7/29/21, 8/3/21, 8/5/21, 8/10/21, 8/12/21, 8/19/21. The record lacked documentation the hha screened the Pt. for COVID-19 symptoms, prior to the visits indicated above. 6. Pt. #5. SOC 9/30/20. Principal Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 8/24/21 at 10:30 AM. The record included PT visit notes for services provided on 7/28/21, 7/30/21, 8/2/21 and 8/4/21. The record lacked documentation the PT screened the Pt. for COVID-19 symptoms, prior to the visits indicated above. 7. During an interview with the Assistant Administrator and Director of Nursing on 8/23/21 at 10:45AM, 11:00AM and 1:30 PM, the above findings were confirmed. 1. The Agency’s “Infection Control” plan was reviewed on 8/23/21 at 2:00 PM. The plan lacked a policy or procedure pertaining to screening for COVID-19 of the Agency’s staff and visitors. 2. Pt. 1. SOC 4/30/21. Primary Diagnosis: Type 2 Diabetes with Diabetic Autonomic (Poly) Neuropathy. The clinical record was reviewed on 8/23/21 at 3:10 PM. The record included the hha visit notes for 2 times a week from 7/27/21 to 8/13/21. The record lacked documentation the hha screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. 3. Pt. #4. SOC 7/7/21. Diagnoses: Essential (Primary) Hypertension and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 8/23/21 at 4:30 PM. The record contained hha visit notes dated 7/15/21, 7/19/21, 7/31/21 and 8/3/21. The record lacked documentation the hha screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. 4. During an interview with the Director of Nursing on 8/23/21 at 2:30 PM, the Director of Nursing stated “We do not screen ourselves, we need to develop something.” As of 8/23/21, the Agency lacked a policy and procedure that staff and visitors are screened for COVID-19, prior to reporting to work or engaging with visitors.

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: A. Based on a review of the Agency's Infection Control plan, Infection Surveillance plan, Agency policy, clinical record review and staff interview, it was determined the Agency failed comply with its policy for Infection Surveillance, and incorporate standards for COVID-19 into the Infection Control and Surveillance plans. This has the potential to affect all Pts. that receive services by the Agency. Findings include: 1. The Agency’s “Infection Control” plan which contained the Agency’s Infection Surveillance plan was reviewed on 8/23/21 at 2:00 PM. The plans lacked written standards related to COVID-19, policies and procedures based on standards for COVID-19, and when the Agency would notify the local Public Health Department pertaining to staff or Pts. confirmed with COVID-19. 2. The Agency’s “Infection Control” plan contained the policy titled, “Post Exposure Evaluation and Follow-up Procedures” which required: “1. Following a report of an exposure incident, the Agency shall refer the employee for…serologic testing… 2. The Agency will make immediately available to the exposed employee a confidential report of: a. Documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred…” 3. Pt. #4. SOC 7/7/21. Diagnoses: Essential (Primary) Hypertension, Unspecified Cerebral Infarction and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 8/23/21 at 4:30 PM. The record contained the “Communication Note” dated 8/19/21 indicating the hospital notified the Agency Pt. #4 would be discharged on 8/20/21, and “…Upon reviewing in-patient discharge note patient positive for Covid-19 and being treated… Called placed to …hha …RN …Medical Staff …hha ...PTA …PT …APN… to inform them of positive result of Covid-19 of above patient and to test themselves due to exposure. As of 8/23/21, the Agency lacked any documentation regarding infection surveillance of the employees indicated above, regarding their exposure to COVID-19. 4. An interview was conducted on 8/24/21 at 7:55 AM with E #2 (hha) identified above. E #2 stated: “Yes, I was exposed to COVID-19, the office called me last week. I had already received my first and second COVID vaccine shots. I did not retest for COVID-19… and didn’t self-quarantine, but I’m monitoring myself for the COVID-19 symptoms every day.” The Agency lacked documentation that the Agency referred E #2, or any of the other exposed staff indicated above for serologic testing, as required by the Agency’s policy. 5. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 10:45 AM, the Director of Nursing confirmed the Infection Control and Infection Surveillance plans were incomplete for persons under investigation for COVID-19.

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: A. Based on a review of clinical records, and staff interview, it was determined the Agency failed to ensure the Home Health Aide provided services, as directed on the Home Health Aide Care Plan. This was found in 1 of 3 (Pt. #3) clinical records reviewed, wherein the Pt. received Home Health Aide services. Findings include: 1. Pt. #3. SOC 2/5/21. Principal Diagnosis: Systemic Lupus Erythematosus. The clinical record was reviewed on 8/24/21 at 9:30 AM. The record contained the "HHA Care Plan" completed by the RN and dated 6/4/21. The Plan required the hha to provide the following personal care every visit: “Assist with Chair Bath, Shower with Chair” Pt. #3’s “HHA visit” notes dated 6/29/21, 7/1/21, 7/6/21, 7/8/21, 7/13/21, 7/15/21, 7/20/21, 7/22/21, 7/27/21, 7/29/21, 8/3/21, 8/5/21, 8/10/21, 8/12/21 and 8/19/21 included documentation that during these visits, the hha also provided Tub Bath and Shower for Pt. #3, which were not indicated in the "HHA Care Plan." 2. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 1:30 PM, the administrative staff confirmed the above 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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the RN conduct Aide supervision every 14 days. This was found in 1 of 3 (Pt. #4) clinical records reviewed, wherein the Pt. received Home Health Aide services. Findings include: 1. Pt. #4. SOC 7/7/21. Diagnoses: Essential (Primary) Hypertension and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 8/23/21 at 4:30 PM. The record contained the hha visit notes, 2 times a week from 7/8/21 to 7/31/21 and 8/3/21. As of 8/23/21, the record lacked documentation the RN conducted any Home Health Aide supervision between 7/8/21 to 8/3/21. 2. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 11:00 AM, the Director of Nursing confirmed the RN failed to supervise the Home Health Aide from 7/8/21 to 8/3/21.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure visit notes were incorporated into the clinical record, in a timely manner. This was found in 3 of 7 (Pts. #1, 3 and 5) clinical records reviewed. Findings include: 2. Pt. #3. SOC 2/5/21. Principal Diagnosis: Systemic Lupus Erythematosus. The clinical record was reviewed on 8/24/21 at 9:30 AM. The clinical record lacked SN notes for the weeks of 8/8/21 to 8/14/21 and 8/15/21 to 8/21/21. During an interview with the Assistant Administrator on 8/24/21 at 1:20 PM, it was revealed that the SN conducted skilled visits on 8/12/21 and 8/19/21 but the SN notes were not yet incorporated in the medical record at the time of the review. 3. Pt. #5. SOC 9/30/20. Principal Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 8/24/21 at 10:30 AM. The clinical record lacked SN notes for the weeks of 8/8/21 to 8/14/21 and 8/15/21 to 8/21/21. During an interview with the Assistant Administrator on 8/24/21 at 1:30 PM, the Assistant Administrator stated the SN submitted “Sign-In Sheet” containing signature of Pt. #5 indicating that visits were conducted on 8/11/21 and 8/15/21 but the SN notes were not yet incorporated in the medical record at the time of the review. 4. During an interview with the Assistant Administrator and Director of Nursing on 8/24/21 at 11:00 AM and 1:30 PM, the Administrative Staff confirmed the above findings. The Assistant Administrator also stated the clinicians should submit clinical notes at least within a week of the visit. 1. Pt. 1. SOC 4/30/21. Primary Diagnosis: Type 2 Diabetes with Diabetic Autonomic (Poly) Neuropathy. The clinical record was reviewed on 8/23/21 at 3:10 PM and lacked documentation the SN had conducted any services, during the weeks of 7/25/21 to 7/31/21, 8/1/21 to 8/7/21 and 8/8/21 to 8/14/21. Until, the Agency presented the SN visit notes dated 7/28/21, 8/4/21 and 8/11/21 on 8/24/21. The Agency failed to incorporate SN visit notes, as required by the Agency’s policy.