Every finding on record at Celebrity Health Services, Inc

The following reflects the findings of the California Department of Public Health during a the Recertification Survey conducted on 4/4/23 - 4/6/23 Representing the California Department of Public Health: Surveyor #43979, Health Facilities Evaluator Nurse Surveyor #43929, Health Facilities Evaluator Nurse Census – 14 Sample size – 7 Record Review with Home Visit – 3 Closed Record Review – 2 Record Review without Home Visit: 2 There were 15 deficiencies issued.

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 interview and record review the Home Health Agency (HHA) failed to provide the State toll free complaint number, its hours of operation, and the purpose for two of seven sampled patients (Patient 1 and Patient 2). This deficient practice had the potential to prevent patients from filing and voicing out their grievances. a) During a joint home visit on 4/5/2023 at 11:50 a.m. with the Director of Patient Care Services (DPCS) at Patient 2’s (P2) home, the DPCS was unable to demonstrate and could not show P2’s HHA Patient Admission Folder or the State toll free complaint number, that the patient could use to voice out concern and issues on HHA. b) During a joint home visit on 4/5/2023 at 12:55 a.m. with the Director of Patient Care Services (DPCS) to Patient 1’s (P1) home, DPCS was unable to demonstrate and could not show P1’s HHA Patient Admission Folder or the State toll free complaint number that the patient could use to voice out concern and issues on HHA. During an interview on 4/5/2023 at 2:20 p.m. with the DPCS, DPCS stated, “If they have a complaint about anything including us, they can call that number to make a complaint at any time.” however, the telephone hotline was not provided for the patients. During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “7. If eligibility criteria are met, the patient and family/caregiver will be provided with an organization brochure and various educational materials providing sufficient information on: K. written information regarding the availability and indications for use of the state and ACHC Home Health Hot Line telephone numbers, the hours of operation and that the purpose of the hotline is to receive complaints or questions about local home health agencies.”

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to provide Federal and State funded entity information for three of seven sampled patients (Patient 1, Patient 2, and Patient 4). This deficient practice had the potential to prevent patients be familiar with the services that are available to them. c). A review of Patient 4’s (P4) “Patient Profile” sheet indicated a start of care date of 1/6/2023, with diagnoses including unspecified open wound of the right lower leg. During a joint home visit on 4/5/23 at 9:50 a.m., with the Director of Patient Care Services (DPCS) to Patient 4’s (P4) home, the Home Health Agency folder was reviewed. There was no information for state and/or federal funded entity included in the contents of the folder. a) During a joint home visit on 4/5/2023 at 11:50 a.m. with the Director of Patient Care Services (DPCS) to Patient 2’s (P2) home, DPCS was unable to demonstrate P2’s HHA Patient Admission Folder or any State and Federal funded entity information. b) During a joint home visit on 4/5/2023 at 12:55 a.m. with the Director of Patient Care Services (DPCS) to Patient 1’s (P1) home, DPCS was unable to demonstrate P1’s HHA Patient Admission Folder or any State and Federal funded entity information. During an interview on 4/5/2023 at 2:20 p.m. with the DPCS, DPCS stated, “They need to know what is out there for them, what resources they have.” During a review of facility’s Patient Admission Folder indicated there were no State or Federal funded program in folder. During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “7. If eligibility criteria are met, the patient and family/caregiver will be provided with an organization brochure and various educational materials providing sufficient information on: I. available community resources.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Patient Bill of Rights” dated November 2022 indicated “DD. The names, addressed and telephone numbers of the following Federally funded and state-funded entities that serve the area where the patient resides: 1. Agency on Aging 2. Center for Independent Living 3. Protection and Advocacy Agency 4. Aging and Disability Resource Center 5. Quality Improvement Organization

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure the comprehensive assessment accurately reflected the current health status for three of seven sampled patients (Patient 1, Patient 2, and Patient 4). This deficient practice resulted in incomplete medical records which can affect the patients care and wellbeing and potential for a delay in their care. a) During a record review of Patient 1’s (P1) “Plan of Care” dated from 3/7/2023 to 5/5/2023, indicated P1 had a Start of Care Date of 1/6/2023 with a primary diagnosis of essential primary hypertension (high blood pressure). During a concurrent interview and record review on 4/6/2023 at 2 p.m. with the Director of Patient Care Services (DPCS) of P1’s Electronic Medical Record (EMR) OASIS (Outcome and Assessment Information Set (OASIS) is a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes) follow -up dated 3/3/2023, indicated sections neurological, nutritional status, frequency duration, vital sign parameters, and SN patient centered goal were left blank. DPCS stated, “I propagate them on the POC, I do the POC from the OASIS. Yes, they should be documented on the OASIS. I missed those sections. They are missing on this one.” b) During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. During a record review of P2’s “Comprehensive Adult Assessment – Start of Care Version” dated2/18/2023, indicated section “Orders for Disciplines and Treatments – Frequency/Duration” was left blank. It also indicated section “Measurable Goals and Outcomes – SN (Skilled Nurse) Cardiovascular Goals: BP (blood pressure) range will be within physician established parameters …”. The BP parameters range were not indicated or listed on the form. c). A review of Patient 4’s (P4) “Patient Profile” sheet indicated a start of care date of 1/6/2023, with diagnoses including unspecified open wound of the right lower leg. During an interview on 4/5/23, at 9:40 a.m., the Director of Patient Care Services (DPCS) stated P4 was receiving HHA services for wound treatment. The DPCS stated the wound was completely healed and there was a presence of a “dot” which the agency was keeping an eye on it to make sure it doesn’t get worse. During a concurrent observation and interview on 4/5/23, at 9:43 a.m., a home visit was done with the DPCS to observe the care provided to P4. During an observation of P4’s wound on the right lower leg, a white bandage was observed. The DPCS removed the bandage: the color of the skin had areas of redness, and a scaly, dry, intact skin was observed. The DPCS stated the description of the wound to be “healed traumatic wound with full granulation (a type of new tissue) and epithelization (a process where cells repair a wound)”. During an interview on 4/5/23, at 10:00 a.m., the DPCS stated wound pictures are taken on admission, once a month, and on the recertification period (the time an assessment is done to determine if patient needs HHA services), as part of the wound assessment. The DPCS stated it was important to take pictures of the wound to monitor the wound progress. During an interview on 4/5/23 at 10:06 a.m., the DPCS stated she took pictures of the wound on her cell phone. The DPCS stated she could not find the photos taken of P4 on admission and recertification and stated she should have taken pictures of the wound. A record review of P4’s record titled, “Comprehensive Adult Assessment, 485 P.O.C. Worksheet and Outcome and Assessment Information Set”, dated 1/6/2023, indicated, “M0100 This Assessment is Currently Being Completed for the Following Reason: Start of care-further visits planned…Section M-Skin Conditions, key type 1-skin lesion, 2-pressure Ulcer, 3- Stasis Ulcer, 4-Surgical Wound, 5-other (specify), no entries were recorded. Further review of the record indicated, “Section M-Skin conditions” did not have any entries recorded for fields “size, wound bed, drainage, amount, odor, stage, surrounding skin. During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “15. The initial written assessment will be completed within 24 hours of the initial assessment/admission visit. All documentation needed to develop the plan of care will be completed and turned into the office no later than the next business day.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Patient Bill of Rights” dated November 2022 indicated “I. the expected outcomes of care, including patient-identified goals, and anticipated risk and benefits; as well as any factors that could impact treatment effectiveness.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Data Collection and Review” dated 2000, indicated “2. Admission Documentation – The complete admission documentation should be submitted to the agency office within two (2) days after the admission visit.”

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to review and document all the current medications for three of seven sampled patients (Patient 1, Patient 2, and Patient 4). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. a) During a record review of Patient 1’s (P1) “Plan of Care” dated from 3/7/2023 to 5/5/2023, indicated P1 had a Start of Care Date of 1/6/2023 with a primary diagnosis of essential primary hypertension (high blood pressure). During a concurrent interview and record review on 4/5/23 at 12:55 p.m. with P1’s Care Giver 1 (CG1) review of P1’s Board and Care (B&C) “Medication Administration Record” indicated P1 was being administer Nuedexta (treatment of Pseudobulbar Affect (PBA) is a medical condition that causes involuntary, sudden, and frequent episodes of crying and/or laughing in people living with certain neurologic conditions or brain injury) 10 milligrams (mg) twice daily. CG1 stated that she does not have the HHA’s medication profile. CG stated, “We use this list, I don’t have that one.” During a concurrent interview and record review on 4/6/2023 at 2 p.m. with the Director of Patient Care Services (DPCS) of P1’s Electronic Medical Record (EMR) “Medication Profile” dated from 3/7/23 to 5/5/23, the profile did not list Nuedexta. DPCS stated, “It needs to be updated so that anyone can pick it up and know what is going on. If I hear something that is new, I will revise it. On recertification, that is when we do a new med list. Anything else is updated, in between recert, we do reconciliation. I did not reconcile, I didn’t update, it wasn’t done properly. I didn’t reconcile with the new medication.” b) During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. During a concurrent interview and record review on 4/5/23 at 11:50 a.m. with P2’s Care Giver 1 (CG1) review of P2’s Board and Care (B&C) “Medication Administration Record” indicated P2 was being administer “Gabapentin 100 mg one capsule three times per day.” CG1 stated that she gives P2 Gabapentin three times per day, every day. During a concurrent interview and record review on 4/6/2023 at 3 p.m. with the Director of Patient Care Services (DPCS) of P2’s Electronic Medical Record (EMR) “Medication Profile” dated from 2/18/23 to 4/18/23, the profile indicated “Gabapentin 100 mg one capsule three times per day /PRN (as needed). DPCS stated, “I need to update it.” c) A review of Patient 4’s (P4) “Patient Profile” sheet indicated a start of care date of 1/6/2023, with diagnoses including unspecified open wound of the right lower leg. During a concurrent observation and interview on 4/5/23, at 9:55 a.m., a home visit was done with the DPCS to observe the care provided to P4. During the visit the DPCS did not check the medications P4 was taking. The DPCS stated she did not have a medication list with her during the visit because she forgot it. During a concurrent interview and record review of P4’s record titled, “Physician’s Orders”, dated 4/5/23 was reviewed with the DPCS. The DPCS stated the medications listed were probably from the hospice agency. The DPCS stated, “I’m sorry, I should’ve checked and updated the medication list.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Reassessment/Recertification” dated November 2022, indicated “3. The update of the comprehensive assessment must, at a minimum, include: B. Drug regimen review of all medications… 6. Revision to the plan of care shall be communicated as follows: C. All communication shall be documented in the clinical record and the plan of care shall be updated and a verbal order sent to the physician.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Medication Profile” dated November 2022, indicated “Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. 3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. 4. Each patient will receive appropriate written material for specific medications he/she is receiving. During a record review of Home Health Agency (HHA) policy and procedure titled, “Medication Monitoring” dated November 2022, indicated “Ongoing patient medication monitoring will use a collaborative approach between clinicians… will be used to improve the patient’s medication regime.”

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA) failed to perform a complete wound assessment for two of seven sampled patients (Patient 2 and Patient 4). This deficient practice had the potential for ineffective treatment for a specific wound that could cause a delay in wound healing and could affect the patients psychosocial well-being a) During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. P2’s wound treatment ordered was not documented the patient's POC. During a record review of P2’s “Medical Doctor (MD) Start of Care (SOC) Order” dated 2/18/2023, indicated “SN (Skilled Nurse) to perform wound care: Right foot, cleanse with saline, pat dry, apply Xeroform to open areas, cover with bulky dry 4x4 gauze, wrap with Kerlex and conmform roll, with tape to secure.” During a record review of P2’s “Skilled Nurse Visit Note (RN)” dated 3/8/2023, indicated under section “Wound Description: Lesion - Other Scales; Location – Right Foot; Stages – left blank; L – cm; W – cm; D – cm; Tissue CLR – Slough; Drng Amt – Minimal; Drng Clr – Serous; Odor – None; Tunnel – N/A.” During a record review of P2’s “Skilled Nurse Visit Note (RN)” dated 3/11/2023, indicated under section “Wound Description: Lesion - Other Scales; Location – Right Foot; Stages – left blank; L – cm; W – cm; D – cm; Tissue CLR – Red; Drng Amt – Minimal; Drng Clr – Serous; Odor – None; Tunnel – N/A.” During a record review of P2’s “Skilled Nurse Visit Note (RN)” dated 3/17/2023, indicated under section “Wound Description: Lesion - Other Scales; Location – Right Foot; Stages – left blank; L – cm; W – cm; D – cm; Tissue CLR – Slough; Drng Amt – Minimal; Drng Clr – Serous; Odor – None; Tunnel – N/A.” During a record review of P2’s “Skilled Nurse Visit Note (RN)” dated 3/24/2023, indicated under section “Wound Description: Lesion - Other Scales; Location – Right Foot; Stages – left blank; L – cm; W – cm; D – cm; Tissue CLR – Slough; Drng Amt – Minimal; Drng Clr – Serous; Odor – None; Tunnel – N/A.” During a record review of P2’s “Skilled Nurse Visit Note (RN)” dated 3/31/2023, indicated under section “Wound Description: Lesion - Other Scales; Location – Right Foot; Stages – left blank; L – cm; W – cm; D – cm; Tissue CLR – Slough; Drng Amt – Minimal; Drng Clr – Serous; Odor – None; Tunnel – N/A.” During a joint home visit on 4/5/2023 at 11:50 a.m. with the Director of Patient Care Services (DPCS) at P2’s home, DPCS was observed performing P2’s right foot wound treatment, there were no measurements taken of the wound. P2’s right foot was observed with several scaly spots on right foot. During an interview on 4/5/2023 at 2:10 p.m. with the DPCS of P2’s wound prognosis, DPCS stated, “It’s gotten better, its healing, specially after the podiatrist saw her in March.” DPCS also stated that she has taken pictures of the wound, but those pictures are on her cell phone and not in P2’s medical record. b) A review of Patient 4’s (P4) “Patient Profile” sheet indicated a start of care date of 1/6/2023, with diagnoses including unspecified open wound of the right lower leg. During an interview on 4/5/23, at 9:25 a.m., the Director of Patient Care Services (DPCS), stated she learned today (4/5/23) P4 was in hospice services since February 8, 2023. The DPCS stated she “was surprised” and this was the first time she learned about patient being in hospice care. During an interview on 4/5/23, at 9:40 a.m., the DPCS stated P4 was receiving HHA services for wound treatment. The DPCS stated the wound was completely healed and there was a presence of a “dot” which the agency was keeping an eye on it to make sure it doesn’t get worse. During a concurrent observation and interview on 4/5/23, at 9:43 a.m., a home visit was done with the DPCS to observe the care provided to P4. During an observation of P4’s wound on the right lower leg, a white bandage was observed. The DPCS removed the bandage: the color of the skin had areas of redness, and a scaly, dry, intact skin was observed. The DPCS stated the description of the wound to be “healed traumatic wound with full granulation (a type of new tissue) and epithelization (a process where cells repair a wound)”. During an interview on 4/6/23, at 3:20 p.m., the DPCS stated the HHA was going to wait for the report of the survey to update the comprehensive assessment and determine when P4 was going to be discharged from HHA services. During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “12. Refusal of services will be documented in the clinical record.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Ongoing Assessments” dated November 2022, indicated “2. Using the standards of care identified by the organization, the clinician will reassess the patient for: L. Progress toward goals and patient needs and problems M. Compliance to treatment and/or medications. 5. Based on each reassessment, the plan of care, including problems, needs, goals, and outcomes will be reviewed and revised accordingly by the clinician. 6. Based on the findings of the reassessment, change/verbal orders will be generated and forwarded to the physician as needed.”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure patients receive the services as specified in the Plan of Care (POC – an individualized written program for a patient that is developed by health care professionals) for five of seven sampled patients (Patients 1, Patient 2, Patient 3, Patient 6, and Patient 7). This deficient practice had the potential to result in lack of care and services to meet the patient care goals. a) During a record review of Patient 1’s (P1) “Plan of Care” dated from 3/7/2023 to 5/5/2023, indicated P1 had a Start of Care Date of 1/6/2023 with a primary diagnosis of essential primary hypertension (high blood pressure). It indicated that P1 frequency was SN (skilled nursing) 1 wk (once a week) 9 (for nine weeks). It also indicated that under section “Interventions” the vital signs parameters, and “Goals” were left blank. During a record review of P1’s “MD order Skilled Nurse Missed Visit” dated 3/31/2023, indicated Director of Patient Care Services (DPCS) signed the order on 4/4/2023. During a concurrent interview and record review on 4/6/2023 at 2 p.m. with the Director of Patient Care Services (DPCS) of P1’s Electronic Medical Record (EMR), DPCS stated, “We usually write a doctor’s order for missed visit. The day that I know that they are not going to be seen that week. He had a missed visit on the 31st of March. I knew that he was going to have a missed visit on that day. I probably wrote that in the last couple of days. I wrote it on the 4th of April. I should have done it on Monday, I don’t have access to my computer on the weekend. The policy says the next business day, I would need to write the order.” b) During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. It indicated that P2 frequency was SN (skilled nursing) 1 wk (once a week) 1 (for one weeks) then 2 wk 8. During a record review of P2’s “Certified Home Health Aide (CHHA) Medical Doctor (MD) Orders” dated 2/23/2023 and signed by the Director of Patient Care Services (DPCS) on 2/22/2023, indicated the order was a telephone order. It also indicated “CHHA to assist with personal care/ADLs (Activities of Daily Living) with frequency of 1w9”. During a concurrent interview and record review on 4/6/2023 at 3 p.m. with the Director of Patient Care Services (DPCS) of P2’s Electronic Medical Record (EMR), DPCS stated that she sees P2 once a week. DPCS stated, “She has missed Skilled Nurse (SN) visits for the last 4 weeks, I’ve seen her once a week. There is no communication notes or orders for the missed visits.” DPCS stated, “There are no Certified Home Health Aide (CHHA) notes before this one.” DPCS provided the CHHA Visit Note dated 3/9/23. c) During a record review of Patient 3’s (P3) “Plan of Care” dated from 2/23/2023 to 4/23/2023, indicated P3 had a Start of Care Date of 2/23/2023 with a primary diagnosis of impingement syndrome of left shoulder (the top outer edge of your shoulder blade rubs against your rotator cuff beneath it). It indicated that P2 frequency was SN (skilled nursing) 1 wk (once a week) 1 (for one weeks) then 2 wk 8. During a record review of P3’s “MD order Skilled Nurse Missed Visit” dated 3/1/2023, indicated Director of Patient Care Services (DPCS) signed the order on 4/4/2023. During a record review of P3’s “MD order Skilled Nurse Missed Visit” dated 3/8/2023, indicated Director of Patient Care Services (DPCS) signed the order on 4/4/2023. During a record review of P3’s “MD order Skilled Nurse Missed Visit” dated 3/23/2023, indicated Director of Patient Care Services (DPCS) signed the order on 4/4/2023. During a record review of P3’s “MD order Skilled Nurse Missed Visit” dated 3/29/2023, indicated Director of Patient Care Services (DPCS) signed the order on 4/3/2023. During a record review of P3’s “MD order Skilled Nurse Missed Visit” dated 3/30/2023, indicated Director of Patient Care Services (DPCS) signed the order on 4/4/2023. During a concurrent interview and record review on 4/6/2023 at 2:30 p.m. with the Director of Patient Care Services (DPCS) of P3’s Electronic Medical Record (EMR), the DPCS was unable to locate documentation P3 declined Skilled Nursing (SN) visits. DPCS stated, “There is no documentation that she refused the SN visits.” d). A review of Patient 6’s (P6) “Patient Profile” sheet indicated a start of care date of 2/2/2022, with diagnoses including pressure ulcer of left heel, stage 2 (partial opening of the skin with a red or pink wound bed, without slough or bruising). During an interview on 4/6/23, at 3:07 p.m., the Director of Patient Care Services (DPCS) stated P6 received physical therapy services for care during 8/1/22 to 9/29/22. The DPCS stated the P6’s plan of care did not indicate interventions and visit frequency for physical therapy. e). A review of Patient 7’s (P7) “Patient Profile” sheet indicated a start of care date of 10/25/22, with diagnoses including Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions. During an interview on 4/6/23 at 3:00 p.m., the Director of Patient Care Services (DPCS) stated P7 received nursing visits once a week. The DPCS stated the visits were missed and stated she did not follow the care plan. The DPCS stated it was important to follow the plan of care because you have to make progress with the health status of the patient, and you have to do what the doctor ordered. During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “12. Refusal of services will be documented in the clinical record.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Home Health Aide Supervisory Visits” dated November 2022, indicated “3. The registered nurse and/or appropriate skilled professional will be responsible for: A. Supervision of all services provided for in the plan of care.” During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “12. Refusal of services will be documented in the clinical record.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Missed Visits” dated November 2022, indicated “2. If a visit is missed and not rescheduled the clinician will: B. Document in the patient’s clinical record… 5. If a patient routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to include information required in the Plan of Care (POC - an individualized written program for a patient that is developed by health care professionals) for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient7). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being a) During a concurrent interview and record review on 4/6/2023 at 2 p.m. with the Director of Patient Care Services (DPCS) of P1’s Electronic Medical Record (EMR) Plan of Care (POC) dated from 3/7/23 to 5/5/23, indicated P1 had a Start of Care Date of 1/6/2023 with a primary diagnosis of essential primary hypertension (high blood pressure). It also indicated that under section “Interventions” the vital signs parameters, and “Goals” were left blank. DPCS stated, “It should have those; Interventions: you need to know why and what you are going to do with the patient and you need to know the starting point and ending point for the patient. Parameters: So, you will know when to talk to the doctor about the patient, know the highs and lows. I don’t have parameters from the doctor. We need to know when to alert the physician if something changes.” b) During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. It also indicated P2’s wound treatment was not documented on the POC. Lastly, it indicated under section “Goals – SN (Skilled Nurse) Cardiovascular Goals: BP (blood pressure) range will be within physician established parameters …”. The BP parameters range were not mentioned or listed on the POC. During a concurrent interview and record review on 4/6/2023 at 3 p.m. with the Director of Patient Care Services (DPCS) of P2’s Electronic Medical Record (EMR), DPCS was unable to locate P2’s wound treatment order and the physicians established BP parameters. DPCS stated, “You have to know what you need to do, so they can comply with the doctors request. Continuity of care.” c) During a record review of Patient 3’s (P3) “Plan of Care” dated from 2/23/2023 to 4/23/2023, indicated P3 had a Start of Care Date of 2/23/2023 with a primary diagnosis of impingement syndrome of left shoulder (the top outer edge of your shoulder blade rubs against your rotator cuff beneath it). It also indicated the parameters under the Goals section were left blank. During a concurrent interview and record review on 4/6/2023 at 2:30 p.m. with the Director of Patient Care Services (DPCS) of P3’s Electronic Medical Record (EMR) Plan of Care (POC) the DPCS stated, “There are no goal parameters, she needs them there. I don’t see no orders for the parameters, specific.” d). A review of Patient 4’s (P4) “Patient Profile” sheet indicated a start of care date of 1/6/2023, with diagnoses including unspecified open wound of the right lower leg. During a concurrent interview and record review on 4/6/23, at 2:51 p.m., P4’s record titled, “Plan of Care”, for certification period 3/7/2023-5/5/2023, was reviewed with the Director of Patient Care Services (DPCS). The DPCS stated there was no skilled nursing interventions, wound care treatment, no parameters for the vital signs (blood pressure, heart rate, respiration rate, temperature), and no assessments. The DPCS stated it was important because the nursing staff needed to know why they are there, what will be done, and what the goals for care are. A record review of P4’s medical record titled, “MD Recertification Order”, dated 3/4/23, indicated, “SN (skilled nurse) to assess VS (vital signs) and report s/s (signs and symptoms) to MD (doctor)…SN to perform wound are to right lower leg cleanse with Saline (a type of salt based solution), apply Xeroform (a type of bandage) 4x4 (size) dry gauze (a type of bandage), wrap with Kerlex roll gauze, secure with Coban. e). A review of Patient 7’s (P7) “Patient Profile” sheet indicated a start of care date of 10/25/22, with diagnoses including Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions. During a concurrent interview and record review on 4/6/23, at 2:51 p.m., P7’s record titled, “Plan of Care”, for certification period 10/25/2022-12/23/2022, was reviewed with the Director of Patient Care Services (DPCS). The DPCS stated there was no skilled nursing interventions, wound care treatment, no parameters for the vital signs (blood pressure, heart rate, respiration rate, temperature), and no assessments. The DPCS stated it was important because the nursing staff needed to know why they are there, what will be done, and what the goals for care are. A record review of P7’s medical record titled, “MD SOC Order”, dated 10/25/22, indicated, “SN to perform wound care: bilateral (both) foot wounds. Cleanse with Saline apply xeroform cover with dry 4x4 gauze, secure with kerlex, conform roll gauze, tape to secure. SN to assess VS and report to MD…” During a record review of Home Health Agency (HHA) policy and procedure titled, “Reassessment/Recertification” dated November 2022, indicated “6. Revision to the plan of care shall be communicated as follows: C. All communication shall be documented in the clinical record and the plan of care shall be updated and a verbal order sent to the physician.” During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “7. Upon acceptance … the patient will be provided various educational materials… with sufficient information on: A. Nature and goals of care and services.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Patient Bill of Rights” dated November 2022 indicated “I. the expected outcomes of care, including patient-identified goals, and anticipated risk and benefits; as well as any factors that could impact treatment effectiveness.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Care Planning Process” dated November 2022, indicated “1. Individualized Plan of Care: The patient-specific clinical plan of care includes: D. All patient care orders including verbal orders. G. Measurable outcomes and goals identified by the organization and the patient, and the patient anticipated to occur as a result of implementing and coordinating the plan of care. N. Orders for patient-specific…treatments and procedures, including the amount, frequency, and duration. 3. Based on the assessment and conclusion, the plan of care will include, but will not be limited to: A. Patient specific interventions and education.”

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 observation, interview and record review, the Home Health Agency (HHA) failed to follow the Medical Doctors (MD) orders for two of seven sampled patients (Patient 2 and Patient 3). Patient 2’s wound treatment and Patient 3’s Occupational Therapist Evaluation. This failure resulted in patients not receiving the regime prescribed by the physician which had the potential to result in delay of care with a possibility of affecting the patients well-being. a) A review of Patient 2’s (P2) “Plan of Care” (POC) dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. P2’s wound treatment ordered was not documented on her POC. A review of P2’s “MD (Medical Doctor) SOC (Start of Care) Order” dated 2/18/2023, indicated “SN (Skilled Nurse) to perform wound care: right foot, cleanse with saline (a mixture of sodium chloride [salt] and water), pat dry, apply Xeroform (a type of dressing) to open areas, cover with bulky dry 4x4 gauze, wrap with Kerlex (a type of dressing) and conform roll, with tape to secure.” During a joint home visit on 4/5/2023 at 11:50 a.m. with the Director of Patient Care Services (DPCS) at P2’s home, DPCS removed old dressing on P2’s right foot, used Derma wound cleaner (a solution to wash the wound) to assist in the removal process. Old xeroform dressing was then removed. The DPCS placed the new xeroform dressing and on top of the new xeroform dressing, dry dressing was placed. DPCS was observed applying the new dressing before cleaning the wound with saline. During an interview on 4/5/2023 at 2:10 p.m. with the DPCS, DPCS was asked if she followed the doctors’ wound treatment ordered. DPCS stated, “No, I missed that step. I usually spray it really well. I typically use that to avoid any kind of infection and make sure the wound heals properly.” b) A review of Patient 3’s (P3) “Plan of Care” dated from 2/23/2023 to 4/23/2023, indicated P3 had a Start of Care Date of 2/23/2023 with a primary diagnosis of impingement syndrome of left shoulder (the top outer edge of your shoulder blade rubs against your rotator cuff beneath it). It indicated frequency of SN (skilled nursing) visits of once a week) for one week then twice a week for eight week (2 wk 8), PT (Physical Therapist) visits twice a week for four week (2 wk 4) starting week of 2/26/2023, and OT (Occupational Therapist) visits twice a week for 4 week (2 wk 4) starting week of 2/26/2023. During a concurrent interview and record review of P3’s Electronic Medical Record (EMR) with the DPCS on 4/6/2023 at 2:30 p.m., the DPCS was unable to locate the OT notes. DPCS stated, “She declined the OT evaluation. There is no documentation that she refused the OT evaluation.” A review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “12. Refusal of services will be documented in the clinical record.” A review of Home Health Agency (HHA) policy and procedure titled, “Patient Bill of Rights” dated November 2022, indicated “G. The… The organization shall ensure that the patient receives all services outlined in the plan of care.”

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the Plan of Care (POC - an individualized written program for a patient that is developed by health care professionals) was revised for two of seven sampled patients (Patient 2 and Patient 6). This failure resulted in health status decline due to staff not being aware of the treatments and interventions needed to meet the patient needs. a) A record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. It indicated that P2 frequency was SN (skilled nursing) visit once a week for one week then twice a week for eight weeks (2 wk 8). A record review of P2’s “CHHA (Certified Home Health Aide) MD (Medical Doctor) Orders” dated 2/23/2023 and signed by the Director of Patient Care Services (DPCS) on 2/22/2023, indicated the order was a telephone order. It also indicated “CHHA to assist with personal care/ADLs (Activities of Daily Living) with frequency of once a week for nine weeks (1w9)”. A record review of P2’s “Inter Office Communication Note” dated 3/2023, indicated “Change CHHA frequency to twice a week (2 x wk), starting 3/13/2023.” During a concurrent interview and record review of P2’s electronic medical record (EMR) with the DPCS on 4/6/23 at 1:36 p.m., the DPCS stated, “We made an inter-office communication note that the patient requested CHHA twice a week. I forgot to write the order for the change of CHHA frequency.” b). A review of Patient 6’s (P6) “Patient Profile” sheet indicated a start of care date of 2/2/2022, with diagnoses including pressure ulcer of left heel, stage 2 (partial opening of the skin with a red or pink wound bed, without slough or bruising). During an interview on 4/6/2023, at 3:07 p.m., the DPCS stated P6 received skilled nursing and physical therapy services for care during 8/1/2022 to 9/29/2022. The DPCS stated there was no doctor order for physical therapy services in P6’s record. The DPCS stated the only physical therapy order present was the one in the referral order. The DPCS stated a doctor’s order was needed after the evaluation of physical therapy services, to establish the frequency of visit from physical therapy. A review of Home Health Agency (HHA) policy and procedure titled, “Reassessment/Recertification” dated November 2022, indicated “6. Revision to the plan of care shall be communicated as follows: C. All communication shall be documented in the clinical record and the plan of care shall be updated and a verbal order sent to the physician.” A review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “The patient’s physician must order and approve the provision of any service. A skilled service must be ordered.” A review of Home Health Agency (HHA) policy and procedure titled, “Patient Bill of Rights” dated November 2022, indicated “F. Be advised in advance of the disciplines that will furnish care, and the frequency of visits proposed to be furnished. H. The establishment and revision of the plan of care, including the disciplines that will furnish the care and the frequency of visits as well as any changes in the are to be furnished.” The policy indicated “I. the expected outcomes of care, including patient-identified goals, and anticipated risk and benefits; as well as any factors that could impact treatment effectiveness.” A review of Home Health Agency (HHA) policy and procedure titled, “Care Planning Process” dated November 2022, indicated “1. Individualized Plan of Care: The patient-specific clinical plan of care includes: D. All patient care orders including verbal orders. G. Measurable outcomes and goals identified by the organization and the patient, and the patient anticipated to occur as a result of implementing and coordinating the plan of care. N. Orders for patient-specific…treatments and procedures, including the amount, frequency, and duration. S. Frequency and duration of visits. 3. Based on the assessment and conclusion, the plan of care will include, but will not be limited to: A. Patient specific interventions and education. I. All pertinent diagnoses. K. All medications. 16. The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule… B. Patient medication schedule/instructions… C. Any treatments to be administered…” A review of Home Health Agency (HHA) policy and procedure titled, “Ongoing Assessments” dated November 2022, indicated “2. Using the standards of care identified by the organization, the clinician will reassess the patient for: L. Progress toward goals and patient needs and problems, M. Compliance to treatment and/or medications. 5. Based on each reassessment, the plan of care, including problems, needs, goals, and outcomes will be reviewed and revised accordingly by the clinician. 6. Based on the findings of the reassessment, change/verbal orders will be generated and forwarded to the physician as needed.” A review of Home Health Agency (HHA) policy and procedure titled, “Verification of Physician Orders” dated November 2022, indicated “Orders will be obtained from a licensed physician for care and services to be provided to home health patients.”

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to coordinate the care for two of seven sampled patients (Patient 2 and Patient 4). This failure resulted in the HHA not being aware of the services the patients were receiving which can result in a delay or care and in an inaccurate treatment regime. b). A review of Patient 4’s (P4) “Patient Profile” sheet indicated a start of care date of 1/6/2023, with diagnoses including unspecified open wound of the right lower leg. During an interview on 4/5/23, at 9:25 a.m., the Director of Patient Care Services (DPCS), stated she learned today (4/5/23) P4 was in hospice services since February 8, 2023. The DPCS stated she “was surprised” and this was the first time she learned about patient being in hospice care. During an interview on 4/5/23 at 3:37 p.m., the Health Services Director (HSD) of the assisted living facility, where P4 resides, stated he was notified of P4’s admission to hospice care (care provided to the terminally ill) on 2/8/23. The HSD stated he did not notify the HHA about the admission to hospice care because he was out of the country. The HSD stated he was surprised to see the DPCS on 4/5/23 because he had assumed HHA services had stopped because the HHA had not turned in a 3rd party outside communication form (OCF). The HSD stated, “the expectation is they fill out this form and tell us what they do with the patient. It is an internal form. If the agency does not fill it out we have to figure out what’s going on. Why they didn’t fill out the form. We call them if they didn’t fill out the form.” The HSD stated the last time the HHA turned in an OCF was on 10/26/22. During an interview on 4/6/23, at 2:55 p.m., the DPCS stated the process for care coordination for patients living at an assisted living facility was to speak to the medication coordination and the staff to make sure the HHA knows what is going on with the visits. The DPCS stated the assisted living facility staff needed to be notified of what the HHA was doing. The DPCS stated, “typically there is a form we will out, we are supposed to fill it out every visit”. The DPCS stated she did not give the form to the staff at the assisted living facility for the visits conducted during the certification period of 3/7/2023-5/5/2023. When the DPCS was informed that the HSD stated the last form turned in was on 10/26/22, the DPCS stated, “It was probably from the previous nurse. I didn’t know I had to do that. Now I know.” During an interview on 4/6/23, at 3:20 p.m., the DPCS stated the HHA was going to wait for the report of the survey to determine when P4 was going to be discharged from HHA services. During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. P2’s wound treatment ordered was not documented on her POC. During a record review of P2’s “MD (Medical Doctor) SOC (Start of Care) Order” dated 2/18/2023, indicated “SN (Skilled Nurse) to perform wound care: Right foot, cleanse with saline, pat dry, apply Xeroform to open areas, cover with bulky dry 4x4 gauze, wrap with Kerlex and conmform roll, with tape to secure.” During a concurrent interview and record review on 4/6/2023 at 3 p.m. with the Director of Patient Care Services (DPCS) of P2’s Electronic Medical Record (EMR), the DPCS was unable to locate P2’s podiatrist consult documentation. DPCS stated, “She has a podiatrist from Florida that treats her, last time she saw her was early March. There is no documentation from the podiatrist in our system. It was a onetime only, then she went back to Florida. It important to document to know who is on the case and the why and when.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Coordination of Services with Other Providers” dated November 2022, indicated “1. All services to other service providers will be documented in the clinical record. C. Monitoring duplication or conflict of services provided by various organizations or individuals. If anyone is aware of duplication or conflict, attempts to correct the situation are necessary.”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide written information regarding the Plan of Care (POC - an individualized written program for a patient that is developed by health care professionals) and Medication Profiles for three of seven patients (Patient 1, Patient 2, and Patient 4). This deficient practice resulted in patients and their representatives not knowing their care team, treatment course or what medications were ordered. a) A review of Patient 1’s (P1) “Plan of Care” dated from 3/7/2023 to 5/5/2023, indicated P1 had a Start of Care Date of 1/6/2023 with a primary diagnosis of essential primary hypertension (high blood pressure). During a concurrent interview and record review of P1’s Board and Care (B&C) “Medication Administration Record" with P1’s Care Giver 1 (CG1) on 4/5/2023 at 12:55 p.m., CG1 stated that she does not have the HHA’s medication profile. CG1 stated, “We use this list, I don’t have that one either.” P1’s POC was demonstrated to CG1, CG1 stated that she does not have one at home. During a joint home visit on 4/5/2023 at 1:50 p.m. with the Director of Patient Care Services (DPCS) at P1’s home, DPCS was unable to locate P1’s HHA’s folder containing P1’s Medication Profile, POC, or any HHA documents. DPCS stated that she did not provide a medication list because “they use their own”. DPCS stated that she did not provide P1’s POC: “I did not, they need to have them in case you are not there, and other nurses see the patients they need to know what to do, it’s the standard of care for them.” b) A record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. During a concurrent interview and record review of P2’s Board and Care (B&C) “Medication Administration Record” with P2’s Care Giver 1 (CG1) on 4/5/2023 at 11:50 p.m., CG1 stated that she does not have the HHA’s medication profile. CG1 stated, “We use this list, I don’t have that one.” P2’s POC was demonstrated to CG1, CG1 stated that she does not have one at home. During a joint home visit on 4/5/2023 at 2:10 p.m. with the DPCS at P2’s home, DPCS was unable to locate P2’s HHA’s folder containing P2’s Medication Profile, POC, or any HHA documents. DPCS stated that she did not bring a medication list for P2. DPCS stated it was important to have a medication list “to make sure we have everything current and eliminate what we don’t need.” c) A review of Patient 4’s (P4) “Patient Profile” sheet indicated a start of care date of 1/6/2023, with diagnoses including unspecified open wound of the right lower leg. During a concurrent observation and interview on 4/5/23, at 9:55 a.m., a home visit was done with the DPCS to observe the care provided to P4. During the visit, a plan of care and medication list was not in the home. The DPCS stated there was no care plan at the home because she is the only nurse who sees P4 and the DPCS keeps the plan of care and medication list. The DPCS stated she did not have the plan of care and medication list because she forgot it. A review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “7. If eligibility criteria are met, the patient and family/caregiver will be provided with an organization brochure and various educational materials providing sufficient information…” A review of Home Health Agency (HHA) policy and procedure titled, “Patient Bill of Rights” dated November 2022, indicated “J. Be advised in advance of any change, orally and in writing, in the plan of care before the change is made.” A review of Home Health Agency (HHA) policy and procedure titled, “Care Planning Process” dated November 2022, indicated “16. The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule… B. Patient medication schedule/instructions… C. Any treatments to be administered…” A review of Home Health Agency (HHA) policy and procedure titled, “Medication Profile” dated November 2022, indicated “4. Each patient will receive appropriate written material for specific medications he/she is receiving.

Ensuring the overall quality of care provided CFR(s): 484.80(h)(5)(i) Ensuring the overall quality of care provided by an aide; This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure the Certified Home Health Aide (CHHA) was following one of seven sampled patients (Patient 2) Plan of Care. This failure had the potential to delay patients care and possible affect her well-being. During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. It indicated that P2 frequency was SN (skilled nursing) 1 x week (once a week) for one week (1 week) then for 2 week for 8 weeks. A record review of P2’s “CHHA (Certified Home Health Aide) MD (Medical Doctor) Orders” dated 2/23/2023 and signed by the Director of Patient Care Services (DPCS) on 2/22/2023, indicated the order was a telephone order. It also indicated “CHHA to assist with personal care/ADLs (Activities of Daily Living) with frequency of 1 x week(once a week) for 9 weeks”. During a record review of P2’s “Inter Office Communication Note” dated 3/2023, indicated “Change CHHA frequency to 2 x week, starting 3/13/2023.” During a record review of P2’s “CHHA Care Plan” dated 2/23/23, indicated “Check and Report if patient is incontinent (uncontrolled) of: urine, stool, diapers, and document last bowel Movement; Follow Safety Measures: keep side rails up; Take Vital Signs: temperature, blood pressure, pulse; Document Patient’s Response to Care-Report Problems to: RN(Registered Nurse) Case Manager, Clinical Supervisor; Perform Environmental Services: Tidy Patient Area.” During a record review of P2’s “CHHA Visit Note” dated 3/9/2023, indicated sections: Patient Incontinent of, Safety Measures Performed, Vital Signs, and Patient Outcome Observed was left blank. It also indicated CHHA1 signed the visit note on 3/15/2023. During a record review of P2’s “CHHA Visit Note” dated 3/13/2023, indicated section - Patient Outcome Observed was left blank. It also indicated CHHA1 signed the visit note on 3/19/2023. During a record review of P2’s “CHHA Visit Note” dated 3/16/2023, indicated sections: Environmental Needs Performed and Patient Outcome Observed was left blank. It also indicated CHHA1 signed the visit note on 3/19/2023. During a record review of P2’s “CHHA Visit Note” dated 3/20/2023, indicated sections: Environmental Needs Performed and Patient Outcome Observed was left blank. It also indicated CHHA1 signed the visit note on 3/26/2023. During a record review of P2’s “CHHA Visit Note” dated 3/24/2023, indicated sections: Environmental Needs Performed and Patient Outcome Observed was left blank. It also indicated CHHA1 signed the visit note on 3/26/2023. During a record review of P2’s “CHHA Visit Note” dated 3/27/2023, indicated sections: Patient Outcome Observed was left blank. It also indicated CHHA1 signed the visit note on 4/1/2023. During a record review of P2’s “CHHA Visit Note” dated 3/30/2023, indicated sections: Patient Outcome Observed was left blank. It also indicated CHHA1 signed the visit note on 4/1/2023. During a concurrent interview and record review on 4/6/2023 at 3 p.m. with the Director of Patient Care Services (DPCS) of P2’s Electronic Medical Record (EMR) Certified Home Health Aide (CHHA) care plan (an individualized plan of care made to guide the CHHAs duties and responsibilities). DPCS stated, “So that the CHHA can follow what activities and duties they need to do for the patient. They need to follow whatever there is in the care plan. It does not look like she is following the care plan. They need to do the activities that are required for the patient.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Home Health Aide Supervisory Visits” dated November 2022, indicated “3. The registered nurse and/or appropriate skilled professional will be responsible for: A. Supervision of all services provided for in the plan of care. D. Documentation of all pertinent clinical notes, which may include observations made by the aide...” During a record review of Home Health Agency (HHA) Certified Home Health Aide – Job Description Summary” revised January 23, indicated “The home health aide… works under the supervision of a registered nurse. Responsibilities of the home health aide include… 4. Taking and recording oral, rectal, and axillary temperatures, pulse, respiration, and blood pressure when ordered. 5. Assisting in ambulation and exercise according to the plan of care. 7. Performing simple procedures as an extension of nursing services as ordered… 11. Reporting on patient’s condition… to the assigned nurse.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Home Health Aide Plan of Care” dated November 2022, indicated “Each patient receiving home health aide services will have an individualized plan… and utilized to direct the care performed by the assigned aide… 2. The home health aide plan of care will be individualized to the specific patient and will include at least: B. Frequency of visits L. Allergies…” During a review of facility’s policy and procedure titled, “Admission Criteria and Process” revised November 2022, indicated “12. Refusal of services will be documented in the clinical record.”

Supervising HH aide services CFR(s): 484.80(h)(5)(ii) Supervising aide services as described in paragraphs (h)(l) and (2) of this section; and This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to conduct Certified Home Health Aide (CHHA) Supervisory Visits for one of seven sampled patients (Patient 2). This failure had the potential to result in the patient being taken care of by an unqualified staff, which could have delayed care and affect the patients well-being. During a record review of Patient 2’s (P2) “Plan of Care” dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. It indicated that P2 frequency was SN (skilled nursing) 1 x week (once a week) for one week (1 week) then 2 weeks for 8 weeks. A record review of P2’s “CHHA (Certified Home Health Aide) MD (Medical Doctor) Orders” dated 2/23/2023 and signed by the Director of Patient Care Services (DPCS) on 2/22/2023, indicated the order was a telephone order. It also indicated “CHHA to assist with personal care/ADLs (Activities of Daily Living) with frequency of 1x a week for 9weeks ”. During a record review of P2’s “Inter Office Communication Note” dated 3/2023, indicated “Change CHHA frequency to 2 x a week, starting 3/13/2023.” During a concurrent interview and record review on 4/6/2023 at 3 p.m. with the Director of Patient Care Services (DPCS) of P2’s Electronic Medical Record (EMR), DPCS was unable to locate the Certified Home Health Aide (CHHA) supervisory visits. DPCS stated, “Those are once a month, as far as I know. I haven’t conducted, I did not do that, that is my failing again. I didn’t coordinate with her.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Patient Bill of Rights” dated November 2022 indicated “11. Supervisory visits with clinical disciplines will be conducted to ensure these rights are honored and protected according to organization policy.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Home Health Aide Supervisory Visits” dated November 2022, indicated “1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days if the patient is receiving skilled services.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Home Health Aide Supervisory Visits” dated November 2022, indicated “The frequency of supervisory visits… must be conducted no less frequently than every 14 days is the patient is receiving skilled services. 3. The registered nurse and/or appropriate skilled professional will be responsible for: A. Supervision of all services provided for in the plan of care. D. Documentation of all pertinent clinical notes, which may include observations made by the aide...” During a record review of Home Health Agency (HHA) policy and procedure titled, “Home Health Aide Plan of Care” dated November 2022, indicated “8. The Case Manager or other appropriate clinician will supervise the home health aide at least every 14 days to ensure care is provide according to plan.”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview, and record review the Home Health Agency (HHA) failed to ensure clinical records included records needed to accurately reflect the care for one of seven sampled patients (Patient 2). This failure resulted in incomplete clinical records. During a record review of Patient 2’s (P2) “Plan of Care” (POC) dated from 2/18/2023 to 4/18/2023, indicated P2 had a Start of Care (SOC) Date of 2/18/2023 with a primary diagnosis of unspecified open wound, right foot. P2’s wound treatment order was not documented on her POC. During a record review of P2’s “MD (Medical Doctor) SOC (Start of Care) Order” dated 2/18/2023, indicated “SN (Skilled Nurse) to perform wound care: Right foot, cleanse with saline, pat dry, apply Xeroform (dressing to maintain moist wound environment) to open areas, cover with bulky dry 4x4 gauze ( thin fabric use for cleaning or covering a wound), wrap with Kerlex( large dressing use to secure the primary dressing) and conmform ( stretchy bandage use to hold other dressings in place) roll, with tape to secure.” During a concurrent interview and record review on 4/6/2023 at 3 p.m. with the Director of Patient Care Services (DPCS) of P2’s Electronic Medical Record (EMR), the DPCS was unable to locate P2’s podiatrist ( doctor that help with problems with feet) consult documentation. DPCS stated, “She has a podiatrist from Florida that treats her, last time she saw her was early March. There is no documentation from the podiatrist in our system. It was a onetime only, then she went back to Florida. It important to document to know who is on the case and the why and when.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Coordination of Services with Other Providers” dated November 2022, indicated “1. All services to other service providers will be documented in the clinical record. C. Monitoring duplication or conflict of services provided by various organizations or individuals. If anyone is aware of duplication or conflict, attempts to correct the situation are necessary.” During a record review of Home Health Agency (HHA) policy and procedure titled, “Missed Visits” dated November 2022, indicated “5. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician.”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to send all necessary medical information to the primary care practitioner ( doctor you see for your regular health issues) within 5 days of discharge for two of seven sampled patients (Patient 6, and Patient 7). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA a). A review of Patient 6’s (P6) “Patient Profile” sheet indicated a start of care date of 2/2/2022, with diagnoses including pressure ulcer of left heel, stage 2 (partial opening of the skin with a red or pink wound bed, without slough or bruising). A record review of P6’s record titled, “Discharge from Agency Version”, dated 9/12/2022, indicated “Discharge Summary”, no entries were recorded. b). A review of Patient 7’s (P7) “Patient Profile” sheet indicated a start of care date of 10/25/22, with diagnoses including Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions. A record review of P6’s record titled, “Discharge from Agency Version”, dated 12/14/2022, indicated “Discharge Summary”, no entries were recorded. During an interview on 4/6/23 at 3:02 p.m., the Director of Patient Care Services (DPCS) stated she did not see that the HHA sent the discharge summary to the doctor. The DPCS stated the discharge summary should have been sent for P6 and P7 so the doctor knows the HHA is off the case and no longer providing services. During a record review of Home Health Agency (HHA) policy and procedure titled, “Discharge Summary” dated November 2022, indicated “3. A copy of the discharge summary… will be provided to the patient’s primary care practitioner… within five (5) business days of the patients discharge” During a record review of Home Health Agency (HHA) policy and procedure titled, “Discharge Summary” dated November 2022, indicated “3. A copy of the discharge summary… will be provided to the patient’s primary care practitioner… within five (5) business days of the patients discharge”.