Every finding on record at Channel Health Group of Companies, Inc

A recertification survey was conducted on 07/18/2023. The census was 52 Licensed and Certified patients. An exit conference was conducted on 07/27/2023.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to analyze the agency’s response to and maintain documentation of emergency events, and revise the emergency plan, as needed after each actual emergency response for 3 (2020, 2021, and 2022) of 3 years of the survey review period. The agency was unable to evaluate the effectiveness of the plan and to update the plan as needed to ensure staff and clients were able to complete actions necessary for safety during emergencies. During the entrance conference on 07/18/2023 at 1:46 PM the surveyor provided a list of documents needed for review during the survey to the Administrator. The list included the agencies Emergency preparedness plan and documents for 2020, 2021, and 2022. Review of the emergency preparedness binder provided by the Administrator on 07/27/2023 found no evidence the agency implemented and evaluated the effectiveness of the emergency preparedness plan during the COVID-19 pandemic in 2020, the severe winter storm in February 2021, or the severe winter storm in February 2022. An interview was conducted with the Administrator and Alternate Administrator on 07/27/2023. The surveyor asked who was designated as the agency’s Disaster Coordinator. The Administrator stated he was the Disaster Coordinator. The surveyor shared the findings of the review of the emergency preparedness documents and asked for the evidence of the implementation and internal reviews of the agency’s Emergency Preparedness plan pandemic during the COVID-19 pandemic, the severe winter storms of February 2021 and February 2022. The Administrator stated the agency had implemented their disaster plans for the three events listed above. The Administrator stated they did not do reviews and documentation of initiation and evaluation of the Emergency preparedness plan after the three disasters. The Alternate Administrator stated they did fire drills for the building the office was located in annually and had documented those fire drills. Agency policy read in part: EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8” dated 2/01/2019 the Administrator, or designee, will initiate and be responsible for the recovery phase of the Emergency Preparedness and Response Plan…The Administrator will receive a full briefing of all activities of disaster response, and the Disaster Coordinator will develop a disaster recovery plan to include: (1)Response to actions taken, (2) Necessary modifications to plans and procedures, (3) Training needs, (4) Recovery activities to date. Any incidents will be documented with action plans developed…”

A recertification survey was conducted on 07/18/2023. The census was 52 Licensed and Certified patients. An exit conference was conducted on 07/27/2023. Abbreviations DON – Director of Nurses ER – Emergency Room LVN- Licensed Vocational Nurse OT- Occupational Therapy POC – Plan of Care PT – Physical Therapy COVID-19 – Sars coronavirus disease 2019 RN – Registered Nurse OASIS – Outcome Assessment and Information Set

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 observation, record review and interview, the agency failed to ensure the patients’ right to be advised of the contact information for the following Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization (for three of three patients (Patient 1, 2, and 3) who had home visits). The failure placed patients at risk of missing out on resources in the area that might assist them in maintaining their health, finding appropriate housing, and to be able to appeal discharge decisions by the agency. Review of the sample patient admission folder provided by the Administrator on 07/27/2023 at 11:15 PM revealed no contact information for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement Organization. A home visit was made on 07/24/23 at 10:30 AM with Patient 1. The surveyor reviewed the home folder provided by the agency during the home visit. The folder failed to contain contact information for Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The surveyor asked if any information had been removed from the folder and Patient 1 stated nothing had been removed. Patient 1 stated physical therapy services had been stopped in May and the patient felt he still needed physical therapy for balance issues. The surveyor asked if the patient was advised of his right to appeal the discharge of PT services. Patient 1 stated he was not advised and did not know why PT services were stopped. A home visit was made on 07/24/23 at 12:39 AM with Patient 2. The surveyor reviewed the home folder provided by the agency during the home visit. The folder failed to contain contact information for Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The surveyor asked if any information had been removed from the folder and Patient 2 stated nothing had been removed. Patient 2 stated they needed to find another suitable place to live as the patient and his spouse had disabilities and they felt their current housing situation was not beneficial for his respiratory health because of issues with the electricity current and his oxygen equipment and issues with mold. A home visit was made on 07/24/23 at 1:15 PM with Patient 3. The surveyor observed the home folder provided by the agency during the home visit. The folder failed to contain contact information for Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The surveyor asked if any information had been removed from the folder and Patient 2’s spouse stated nothing had been removed. Patient 2’s spouse stated they needed to find another suitable place to live as Patient 3 and her spouse had disabilities and issues with their current residence. During an interview with the Administrator and Alternate Administrator on 07/27/2023 at 11:45 am the surveyor reviewed the findings of the review of the sample admission folder provided by the Administrator. The surveyor asked why the admission folder did not contain the required federally - funded and state - funded resources contact information. The Administrator stated they didn’t understand what was needed. The surveyor asked for a copy of the agency policy on client rights and reviewed the policy requirements that required the contact information for Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization that was required in the agency policy. The Administrator stated they would take care of it. The surveyor shared the results from the home visits and asked if the patients could benefit from the resources. The Administrator stated they would provide the resources to the patients. Review of the agency policy titled: “PATIENT/CLIENT RIGHTS AND RESPONSIBILITIES… RI.2 dated 01/13/2018” read in part: “PURPOSE To ensure all patients/clients, their representatives (if any) and Agency staff acknowledge, observe and implement the patient's/client’s rights and responsibilities. POLICY I. The patient/client and representative (if any) will be informed of the patient’s/client’s rights and responsibilities in a language and manner the individual understands. The Agency will protect and promote the exercise of these rights… Agency staff will be responsible for knowing, observing, and implementing the patient’s / client’s rights … The Patient / Client has the right to: … 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/client resides: 1. Agency on Aging, 2. Center for Independent Living, 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center; and 5. Quality Improvement Organization…”

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, record review, and interview the comprehensive assessment for 5 (1, 2, 3, 5, and 6) of 5 active patient records reviewed failed to contain assessments that reflected the patients’ condition. Patients were at risk of health declines and the nursing care was affected by the lack of a complete and accurate assessments from which the Plans of Care were generated. Review of Patient 1’s clinical record on 07/20/2023 revealed comprehensive assessments dated 04/26/23 and 06/26/23 which were incomplete and failed to contain RN A’s signature. The assessment dated 04/26/23 was mostly blank from pages 2 to 8 of the 10 page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. The assessment dated 06/26/23 documented Patient 1 had a primary diagnosis if Atrial fibrillation (rapid and irregular heart beat), congestive heart failure (lack of efficient pumping action by the heart), cardiomyopathy (thicker heart walls that reduce blood flow out of the heart), cardiomegaly (enlarged heart), a pacemaker (a device to assist the heart to beat effectively), diabetes mellitus type 2 with the last A1C result of 7.7 (abnormal blood sugar metabolism with an A1C of 5.7 or lower being normal.) The 06/26/23 assessment documented Client 1 had an admission to the Emergency Room on 05/11/2023 with shortness of breath and low blood pressure for the previous week. The comprehensive assessment also documented Patient 1’s A1C was 7.7 on 05/16/2023. The record revealed an incomplete comprehensive assessment dated 06/26/2023 which lacked RN A’s signature, and information about durable medical equipment. Review of Patient 1’s clinical record revealed nursing visits by LVN A on 05/04/2023, 05/10/2023, 05/17/2023, 05/24/2023, and 05/31/2023. There were no weights or blood sugar results documented on any of these nurse’s notes. Review of Patient 1’s clinical record revealed nursing visits by LVN B on 06/07/2023, 06/13/2023, and 06/20/2023. There were no weights or blood sugar results documented on any of these nurse’s notes. A home visit was made on 07/24/23 at 10:30 AM with Patient 1. The surveyor asked if the patient was able to weigh. Patient 1 stated he was able to weigh and that the nurse who came on 07/05/2023 weighed the Patient. The surveyor asked if that was the first time the nurses had weighed the Patient during weekly visits and Patient 1 stated it was. The surveyor asked if Patient 1 monitored their weigh daily and Patient 1 stated they did not. The surveyor asked if the nurses checked Patient 1’s blood sugar during the weekly home visits. Patient 1 stated they did not. The surveyor asked if Patient 1 monitored his blood sugars. Patient 1 stated he did not. The surveyor reviewed the home folder provided by the agency during the home visit. The folder failed to contain Patient 1’s weights or blood sugar results. The surveyor asked if any information had been removed from the home folder and Patient 1 stated nothing had been removed. A telephone interview was conducted on 07/25/2023 at 2:51 PM with LVN A. The surveyor asked if the nurse talked to the RN who did the assessment for the clients or the nursing supervisor when beginning care for a new patient. LVN A stated “No.” LVN A stated if they had a question, they would call the doctor or the office and speak with the Administrator. The surveyor asked how LVN A knew what to do for Patient 1. LVN A stated “it wasn’t complicated” and the nurse looked at the patient’s status during the visit and looked at the patients medications, and taught based on the diagnosis and medication list. The surveyor asked what health issues Patient 1 had. LVN A stated they thought hypertension (high blood pressure) was Patient 1’s main issue. LVN A stated they were filling in for another LVN who was out of town for the month of May and late April and they didn’t normally see Patient 1. The surveyor asked if LVN A weighed Patient 1 during the visits. LVN A stated “No.” The surveyor asked why not. LVN A stated: Patient 1 “would tell me he got weighed in the doctor’s office.” The surveyor asked if LVN A checked Patient 1’s blood sugar during visits. LVN A stated they did not and the Patient “didn’t like to be stuck.” A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there was not a completed start of care assessment and Plan of Care for Patient 1 from 04/26/23 to 06/26/2023. RN A stated they were “up to too much” and they “almost have everything up to date. I have been driving 178 miles a day.” The surveyor asked why Patient 1 didn’t have a plan of care for 04/26/23 to 06/26/2023. RN A stated the plans of care were not generated until the nurse completed the comprehensive assessments. Patient 2’s comprehensive assessment lacked all pertinent diagnoses, therapy services, oxygen, and the equipment supplier. Patient 2’s plan of care lacked all services and equipment required (PT and OT services and oxygen equipment including the supplier). Review of the clinical record for Patient 2 on 07/20/2023 revealed a start of care date of 04/08/2023. The initial assessment failed to include a diagnosis of Asthma or other respiratory conditions. The POC contained orders for two medications prescribed for respiratory conditions: Breo Ellipta inhalation powder daily (helps with breathing) and Proventil inhalation aerosol 2 puffs every 4 hours as needed for wheezing (helps with breathing). The assessment failed to include Oxygen and the name and phone number of the durable medical equipment company was blank. The clinical record revealed a physician’s order dated 04/08/2023 for nursing 1 time per week for 9 weeks, Physical and Occupational therapy to evaluate and treat signed by the DON. The comprehensive assessment failed to include PT and OT evaluations. The clinical record revealed a PT evaluation completed on 04/10/2023 which documented Patient 2 had a wound to his right anterior forearm just inferior to the elbow from a fall yesterday where he landed on an oxygen tank. A home visit was made on 07/24/23 at 12:39 AM with Patient 2. The surveyor asked if the patient was on oxygen. The patient stated yes and described use of a liquid oxygen system with a portable tank for travel to appointments. The surveyor asked if the patient had trouble with his breathing and Patient 2 stated he had asthma and the rental he lived in wasn’t good for his breathing problems. The surveyor asked if Patient 2 had physical and occupations therapy services. Patient 2 stated he had physical therapy and had one OT visit and wanted to save OT for after his pending rotator cuff repair surgery. The surveyor asked who supplied the client with oxygen. Patient 2 stated he wasn’t sure but it might be on the equipment and the patient wanted a different kind of oxygen due to the electricity use of the current older equipment. A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there was no Asthma diagnosis, no PT and OT evaluations, and no oxygen and oxygen provider on Patient 2’s start of care assessment. RN A stated they had never seen Patient 2 wear oxygen and she had “missed it.” RN A stated the agency outsources PT and OT and she did not coordinate with them. The RN said that they only see the agency’s patient’s every 2 months for the OASIS assessments, and they do not case manage the patients care. Review of the clinical record for Patient 3 on 07/21/2023 revealed a start of care date of 04/08/2023. The clinical record revealed no current plan of care for the care that began on 06/06/2023. The clinical record revealed an assessment dated 06/02/23 which was incomplete and failed to contain RN A’s signature. The assessment dated 06/02/23 was mostly blank from pages 2 to 8 of the 10-page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. A home visit was made on 07/24/23 at 1:15 PM with Patient 3. The surveyor observed the home folder provided by the agency during the home visit. The folder contained vital signs documented weekly by LVN C in April and May 2023 and then LVN A in June. The surveyor asked Patient 3’s spouse how often nurses came to see Patient 3. Patient 3’s spouse stated LVN C visited them weekly for a couple of months, then LVN C stopped coming, and then Patient 3 had LVN A, who also came every week. The surveyor asked what health problems Patient 3 had. Patient 3’s spouse stated Patient 3 had Diabetes, a rare brain disorder called Moya Moya which causes dementia and bleeding in the brain, cirrhosis of the liver, and was losing too much weight. Review of Patient 5’s clinical record on 07/20/2023 revealed comprehensive assessments dated 04/27/23 and 06/26/23 which were incomplete and failed to contain RN A’s signature. The assessment dated 04/27/23 was mostly blank from pages 2 to 8 of the 10 page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. Neither of the assessments contained weights and blood sugars for the patient whose primary diagnosis on the plan of care dated 01/02/2023 to 03/02/2023 was Heart Failure (disease of the heart rendering the heart unable to pump enough blood to meet the bodies’ needs), and whose other diagnoses were chronic kidney disease, stage 4 (severe impairment of the kidneys), and Type 2 Diabetes (blood sugar disorder). Review of Patient 6’s clinical record on 07/21/2023 revealed comprehensive assessment dated 06/15/23 which was incomplete and failed to contain RN A’s signature. The assessment dated 06/15/23 was mostly blank from pages 2 to 8 of the 10 page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked reviewed the incomplete assessments found during the record review and asked why they were not completed. RN A stated they were “up to too much” and they “almost have everything up to date. I have been driving 178 miles a day.” The surveyor asked why the assessments were partially completed. The RN stated they opened the assessments and put vitals in and then saved them to finish them later. The surveyor asked about the missing plans of care. RN A stated the plans of care were not generated until the nurse completed the comprehensive assessments. The surveyor asked about wound care orders for Patient 6. RN A stated she didn’t think the patient had a wound. The surveyor asked why LVN A would document wound care orders on visit notes dated 06/22/2023 and 06/29/2023. RN A reviewed the record and explained the nurses can pull old information from previous care episodes over to the current note or assessment. A telephone interview was attempted with the DON on 07/25/2023 at 4:42 PM and 07/27/2023 at 4:06 PM. The DON did not return the calls. A telephone interview was conducted with the Alternate Clinical Director on 07/25/2023 at 5:41 PM. The surveyor asked the Alternate Clinical Director about the missing assessments and plans of care for Patients 1,2,3,5 and 6). The Alternate Clinical Director stated they didn’t work with Patients 1,2, 3, 5, and 6 and could not answer the questions. An interview was conducted on 07/27/2023 at 2:15PM with the Administrator and Alternate Administrator. The surveyor reviewed the findings of the record reviews review and home visits with Patient’s 1, 2, and 3 and the record reviews for Patient’s 5 and 6. The surveyor asked about the assessments that were not complete. The Administrator stated RN A worked with the patients the surveyor had chosen and not the Alternate Clinical Director. The Administrator stated RN A is good with the patients and works at a hospital full time too and usually gets all her documentation done by the end of the month. The Administrator stated: “changing the DON is the thing I need to do because she hasn’t been doing her job .” The surveyor asked how long the Administrator felt the DON hasn’t been doing her job. The Administrator stated the DON was “also working in a hospital and has been the DON since 2017.” Agency policy and procedures titled: Patient / Client Assessment Guidelines PE 2 dated 03/01/2019 read in part: The Agency will use and adhere to a defined comprehensive assessment in order to identify the patient’s/client’s needs for home care and that meets the patient’s/client’s medical, nursing, rehabilitative, social and discharge planning needs.

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, record review, and interview the agency failed to ensure each patient received the home health services that were 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 for 3 (1,2, and 3) of 3 patients who received home visits during the survey. The outcome was the clients’ health was at risk due to the lack of development of patient specific measurable outcomes, assessment and treatments by the nurses who provided weekly care without a plan of care. Client 1’s admission to the Emergency room may have been preventable. Review of the clinical record for Patient 1 on 07/20/2023 revealed a start of care date of 03/02/2023. The clinical record revealed no current plan of care for the period reviewed (04/26/23 to 06/26/2023). The clinical record revealed an unfinished and mostly blank comprehensive assessment by RN A on 04/26/2023. The record revealed a completed comprehensive assessment dated 06/26/2023 which documented Patient 1 had a primary diagnosis if Atrial fibrillation (rapid and irregular heart beat), congestive heart failure (lack of efficient pumping action by the heart), cardiomyopathy (thicker heart walls that reduce blood flow out of the heart), cardiomegaly (enlarged heart), a pacemaker (a device to assist the heart to beat effectively), diabetes mellitus type 2 with the last A1C result of 7.7 (abnormal blood sugar metabolism with an A1C of 5.7 or lower being normal.) The comprehensive assessment documented Patient 1 had an admission to the Emergency Room on 05/11/2023 with shortness of breath and low blood pressure for the previous week. The comprehensive assessment also documented Patient 1’s A1C was 7.7 on 05/16/2023. Review of Patient 1’s clinical record revealed nursing visits by LVN A on 05/04/2023, 05/10/2023, 05/17/2023, 05/24/2023, and 05/31/2023. There were no weights or blood sugar results documented on any of these nurse’s notes. Review of Patient 1’s clinical record revealed nursing visits by LVN B on 06/07/2023, 06/13/2023, and 06/20/2023. There were no weights or blood sugar results documented on any of these nurse’s notes. A home visit was made on 07/24/23 at 10:30 AM with Patient 1. The surveyor asked if the patient was able to weigh. Patient 1 stated he was able to weigh and that the nurse who came on 07/05/2023 weighed the patient. The surveyor asked if that was the first time the nurses had weighed the patient during weekly visits and Patient 1 stated it was. The surveyor asked if Patient one monitored his weigh daily and Patient 1 stated he did not. The surveyor asked if the nurses checked Patient 1’s blood sugar during the weekly home visits. Patient 1 stated they did not. The surveyor asked if Patient 1 monitored his blood sugars. Patient 1 stated he did not. The surveyor reviewed the home folder provided by the agency during the home visit. The folder failed to contain Patient 1’s weights or blood sugar results. The surveyor asked if any information had been removed from the home folder and Patient 1 stated nothing had been removed. A telephone interview was conducted on 07/25/2023 at 2:51 PM with LVN A. The surveyor asked if the nurse talked to the RN who did the assessment for the patients or the nursing supervisor when beginning care for a new patient. LVN A stated “No.” LVN A stated if they had a question, they would call the doctor or the office and speak with the Administrator. The surveyor asked how LVN A knew what to do for Patient 1. LVN A stated it wasn’t complicated and they looked at the patient’s status during the visit and looked at the patients’ medications and taught based on the patient’s diagnosis and medication list. The surveyor asked what health issues Patient 1 had. LVN A stated they thought hypertension (high blood pressure) was Patient 1’s main issue. LVN A stated they were filling in for another LVN who was out of town for the month of May and late April, and they didn’t normally see Patient 1. The surveyor asked if LVN A weighed Patient 1 during the visits. LVN A stated “No.” The surveyor asked why not. LVN A stated: Patient 1 “would tell me he got weighed in the doctor’s office.” The surveyor asked if LVN A checked Patient 1’s blood sugar during visits. LVN A stated they did not and the patient “didn’t like to be stuck.” A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there was no Plan of Care for Patient 1 from 04/26/23 to 06/26/2023. RN A stated RN A was “up to too much” and RN A almost had completed the documentation and had everything up to date. “I have been driving 178 miles a day.” The surveyor asked why monitoring the patient’s weight, edema, and blood sugars and goals for the weight were not on Patient 1’s current plan of care. RN A stated: “I didn’t put it in” (the Plan of Care). The surveyor asked why Patient 1 didn’t have a plan of care for 04/26/23 to 06/26/2023. RN A stated the plans of care were not generated until the nurse completed the comprehensive assessments. Review of the clinical record for Patient 2 on 07/20/2023 revealed a start of care date of 04/08/2023. The clinical record revealed no current plan of care for care that began on 06/06/2023. The clinical record revealed an unfinished and mostly blank comprehensive assessment by RN A on 06/02/2023. A home visit was made on 07/24/23 at 12:39 AM with Patient 2. The surveyor asked Patient 2 who came to see the patient from the home care agency and how often. Patient 2 stated LVN C visited them weekly for a couple of months, then LVN C stopped coming, and then Patient 2 had LVN A who also came every week. Review of the clinical record for Patient 3 on 07/20/2023 at 4:23 PM revealed a start of care date of 04/08/2023. The clinical record revealed no current plan of care for the care that began on 06/06/2023. The clinical record revealed an unfinished and mostly blank comprehensive assessment by RN A dated 06/02/2023. A home visit was made on 07/24/23 at 1:15 PM with Patient 3. The surveyor observed the home folder provided by the agency during the home visit. The folder contained vital signs documented weekly by LVN C in April and May 2023 and then LVN A in June. The surveyor asked Patient 3’s spouse how often nurses came to see Patient 3. Patient 3’s spouse stated LVN C visited them weekly for a couple of months, then LVN C stopped coming, and then Patient 3 had LVN A, who also came every week. A telephone interview was conducted with the Administrator on 07/24/2023 at 4:40 Pm. The surveyor requested phone numbers for Alternate Clinical Director and the DON. The Administrator stated that the DON was on emergency leave for almost a week and her husband was in the ICU. A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there was no current Plan of Care for Patient 2 and Patient 3. RN A stated RN A worked for 20 different agencies as a self- contracted nurse through the electronic medical record and staffing company AA and they were behind on documentation. RN A stated they were working on completing all the incomplete comprehensive assessments on Saturday (07/22/2023.) RN A stated the plans of care were not generated until the nurse completed the comprehensive assessments. A telephone interview was conducted with the Alternate Clinical Director on 07/25/2023 at 5:41 PM. The surveyor asked the Alternate Clinical Director about the missing Plans of Care for Patients 1,2 and 3. The Alternate Clinical Director stated she didn’t work with those patients or RN A, LVN A and LVN C and could not answer the question. A telephone interview was attempted with the DON on 07/25/2023 at 4:42 PM and 07/27/2023 at 4:06 PM. The DON did not return the calls. Agency policy titled: Plan of Care PC.8 dated 03/01/2019 read in part: “Policy – The agency will use data/information gathered during patient / client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems or needs … Procedure – The appropriate professional staff member, with physician participation, is responsible for developing the plan of care within (3) three to (5) five days of the initial assessment… Each patient /client must receive an individualized plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient’s /client’s specific needs as identified in the comprehensive assessment… Each patient / client must receive the home health services that are written in an individualized plan of care that identifies patient / client-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a Doctor of Medicine…” According to the National Institute of Health at https://www.ncbi.nlm.nih.gov/books/NBK574497/ on 07/31/2023 patients with HF (heart failure) require frequent monitoring of vital signs, including oxygen saturation. Frequent assessment and monitoring for symptoms is also indicated. All patients with HF require daily weight monitoring. Nursing care plans for patients with HF must include patient education to improve clinical outcomes and reduce hospital readmissions. Patients need education and guidance on self-monitoring of symptoms at home, medication compliance, daily weight monitoring, dietary sodium restriction to 2 to 3 grams/day, and daily fluid restriction to 2 Liters/day. In addition, patients with HF (heart failure) need aggressive treatment for underlying risk factors and the potential triggers for HF exacerbations. Modifiable risk factors include diabetes mellitus. According to the National Institute of Health at https://www.ncbi.nlm.nih.gov/books/NBK568737/ on 08/07/2023 Hypoglycemia is the most common life-threatening condition which requires immediate nursing management. Extreme hyperglycemia is less common but another possibility. Therefore, nurses must recognize the clinical manifestations of altered blood glucose levels in patients and integrate blood glucose monitoring into the plan of care. Nursing management also includes assessing the patient for complications of type 2 diabetes mellitus and providing patient education relating to the plan of care as well as healthy dietary intake, activity recommendations, and the prescribed medication regimen as needed.

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 observation, record review and interview, the agency failed to ensure the Plan of care for 1 (Patient 2) of 2 active clients records reviewed who had a completed plan of care and 1 (Patient 4) of 2 discharged patient records reviewed contained all required items: Patient 2’s plan of care for the period reviewed lacked all pertinent diagnoses, therapy services, oxygen, and the equipment supplier. Patient 4’s plan of care lacked all pertinent diagnoses and necessary interventions to address the underlying risk factors of the dialysis access site and an abdominal liver abscess (a swollen area within body tissue containing an accumulation of pus). The incomplete plans of care affected the care provided by the agency staff and had the potential to affect client health outcomes. Patient 2’s plan of care for the certification 04/08/2023 to 06/06/2023 lacked all services and equipment required (PT and OT services and oxygen equipment including the supplier). Review of the clinical record for Patient 2 on 07/20/2023 revealed a start of care date of 04/08/2023. The Plan of care failed to include a diagnosis of Asthma or other respiratory conditions. The POC contained orders for Breo Ellipta inhalation powder daily (helps with breathing), Proventil inhalation aerosol 2 puffs every 4 hours as needed for wheezing (helps with breathing.) The POC failed to contain Oxygen and the name and phone number of the durable medical equipment company was blank. The clinical record revealed a physician’s order dated 04/08/2023 for nursing 1 time per week for 9 weeks, Physical and Occupational therapy to evaluate and treat signed by the DON. The plan of care for 04/08/2023 to 06/06/2023 did not include the Physical or Occupational therapy orders for evaluation and treatment. The clinical record revealed a PT evaluation completed on 04/10/2023 which documented Patient 1 had a wound to his right anterior forearm just inferior to the elbow from a fall yesterday where he landed on an oxygen tank. A home visit was made on 07/24/23 at 12:39 AM with Patient 2. The surveyor asked if the patient was on oxygen. The patient stated yes and described use of a liquid oxygen system with a portable tank for travel to appointments. The surveyor asked if the patient had trouble with his breathing and Patient 2 stated he had asthma and the rental he lived in wasn’t good for his breathing problems. The surveyor asked if Patient 2 had physical and occupations therapy services. Patient 2 stated he had physical therapy and had one OT visit and wanted to save OT for after his pending rotator cuff repair surgery. The surveyor asked who supplied the client with oxygen. Patient 2 stated he wasn’t sure, but it might be on the equipment and the patient wanted a different kind of oxygen due to the electricity use of the current older equipment. Review of Patient 4’s plan of care for the certification 08/30/22 to 10/28/22 revealed a diagnosis of end stage renal disease (complete kidney failure), Chronic Obstructive Pulmonary Disease (lung diseases that block airflow and make it difficult to breathe), Hypertension (high blood pressure), Congestive Heart Failure (changes to the structure of the heart that doesn’t allow the heart to pump enough blood for the body’s needs), Neuropathy (nerve damage), Gastro Esophageal Reflux Disease (stomach contents regularly flows into the esophagus), Alcoholic Cirrhosis of the liver (chronic liver damage). Review of the entire plan of care revealed no orders for the assessment of the dialysis access site (a surgical procedure to join and vein and artery to allow for higher pressure and faster blood flow to allow for hemodialysis) for blood flow. Review of the entire plan of care revealed no diagnosis and no orders for the care of the right upper quadrant abdominal drain. Review of the two completed nurses’ notes by LVN B dated 09/06/22 and 09/13/22 revealed no assessment of the blood flow of the patient’s dialysis access site and noted the presence of the abdominal drain and did not document any care provided for the abdominal drain. The record contained a discharge assessment by the DON dated 09/18/2022 documented the patient’s family member notified the nurse the patient passed away on 09/18/2022 due to a lack of dialysis service. A telephone interview was conducted with the Administrator on 07/24/2023 at 4:40 Pm. The surveyor requested phone numbers for Alternate Clinical Director and the DON. The Administrator stated that the DON was on emergency leave for almost a week and her husband was in the ICU. A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there were no orders for checking the blood flow of the dialysis access and no orders for the care of the abdominal drain. RN A stated they thought the orders for the assessment of the AV fistula were on the POC and should have been there. The RN said she was not aware of the abdominal drain and just missed it. An interview was conducted with the Administrator on 07/27/2023 at 1:30 PM. The surveyor reviewed the findings for Patient 4 and asked what happened with the patient. The Administrator stated Patient 4 was admitted looking for a dialysis center. He had been receiving dialysis at a nearby hospital. The Administrator stated they had followed up for Patient 4 with the hospital and they said they were looking for a place for him. The hospital said the patient was not following up and the dialysis center that was set up for Patient 4 refused to take him and declined to tell us the reason. We called and spoke with several local centers telling them his life was on the line. The patient was able to and had gone to the hospital for dialysis while waiting for an available seat at a nearby dialysis center. We also provided numbers to the family to assist the patient and two facilities declined. The Administrator stated the patient and family knew he could have gone back to the hospital. The Administrator stated he told the Patient and the family member to go to the hospital while waiting for an open chair that would be available the third week of September. The Administrator was unable to answer why the POC did not contain the orders for the dialysis access and the diagnosis and orders for the abdominal drain. A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there was no Asthma diagnosis, no PT and OT evaluations, and no oxygen and oxygen provider on Patient 2’s POC. RN A stated they had never seen Patient 2 wear oxygen and she had “missed it.” RN A stated the agency outsources PT and OT and she did not coordinate with them. The RN said that they only see the Patient’s every 2 months for the OASIS assessments and they do not case manager the patients. A telephone interview was attempted with the DON on 07/25/2023 at 4:42 PM and 07/27/2023 at 4:06 PM. The DON did not return the calls. A telephone interview was conducted with the Alternate Clinical Director on 07/25/2023 at 5:41 PM. The surveyor asked the Alternate Clinical Director about the missing items on the Plans of Care for Patients 2 and 4. The Alternate Clinical Director stated they didn’t work with Patient 2 or RN A and could not answer the question for the agency before 01/25/2023. An interview was conducted on 07/27/2023 at 2:15PM with the Administrator and Alternate Administrator. The surveyor reviewed the findings of the review and visit with Patient 2. The surveyor asked by the diagnoses, orders for therapy services, oxygen, and oxygen provider were not on the plan of care. The Administrator stated: “changing the DON is the thing I need to do because she hasn’t been doing her job .” The surveyor asked how long the Administrator felt the DON hasn’t been doing her job. The Administrator stated the DON was “also working in a hospital and has been the DON since 2017.” Agency policy titled Plan of Care PC 8 dated 03/01/2019 read in part: “The Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and / or needs…. Each patient/client must receive an individualized POC, including any revisions or additions. The individualized POC must specify the care and services necessary to meet the patient/client needs as identified in the comprehensive assessment… The individualized Plan of care must include the following: All pertinent diagnoses … The types of services, supplies and equipment required … all medications and treatments … all patient / client care orders, including verbal orders, must be included in the plan of care…” Review of the Lippicott Procedures – Hemodialysis access care, home care dated 5/5/21 revealed in part “…Inspect the AV access extremity and compare it with the other extremity, noting any obvious differences, assess the AV access extremity for swelling, redness, warmth, drainage from prior needle sites, ecchymosis (black and blue areas), …Auscultate for the presence of a bruit (whooshing sound (blood flow) and palpate (touch) the AV access for a continuous sensation, known as a “thrill” (pulse) (patency)…Document all assessments including…as well as your assessment of the AV access extremity and AV access site. Make sure to document the presence or absence of a bruit and thrill…

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, record review, and interview the Administrator failed Be responsible for all day-to-day operations of the HHA and failed to ensure the accurate and timely documentation of services provided for 5 (1,2,3,5, and 6) of 5 active patient records reviewed. The patient records were an incomplete and inaccurate representation of the services provided. Review of Patient 1’s clinical record on 07/20/2023 revealed comprehensive assessments dated 04/26/23 and 06/26/23 which were incomplete and failed to contain RN A’s signature. The assessment dated 04/26/23 was mostly blank from pages 2 to 8 of the 10-page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. The assessment dated 06/26/23 documented Patient 1 had a primary diagnosis if Atrial fibrillation (rapid and irregular heart beat), congestive heart failure (lack of efficient pumping action by the heart), cardiomyopathy (thicker heart walls that reduce blood flow out of the heart), cardiomegaly (enlarged heart), a pacemaker (a device to assist the heart to beat effectively), diabetes mellitus type 2 with the last A1C result of 7.7 (abnormal blood sugar metabolism with an A1C of 5.7 or lower being normal.) The 06/26/23 assessment documented Client 1 had an admission to the Emergency Room on 05/11/2023 with shortness of breath and low blood pressure for the previous week. The comprehensive assessment also documented Patient 1’s A1C was 7.7 on 05/16/2023. The record revealed an incomplete comprehensive assessment dated 06/26/2023 which lacked RN A’s signature, and information about durable medical equipment. A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there was not a completed start of care assessment and Plan of Care for Patient 1 from 04/26/23 to 06/26/2023. RN A stated they were “up to too much” and they “almost have everything up to date. I have been driving 178 miles a day.” The surveyor asked why Patient 1 didn’t have a plan of care for 04/26/23 to 06/26/2023. RN A stated the plans of care were not generated until the nurse completed the comprehensive assessments. Review of the clinical record for Patient 2 on 07/20/2023 revealed a start of care date of 04/08/2023. The initial assessment failed to include a diagnosis of Asthma or other respiratory conditions. The POC contained orders for two medications prescribed for respiratory conditions: Breo Ellipta inhalation powder daily (helps with breathing) and Proventil inhalation aerosol 2 puffs every 4 hours as needed for wheezing (helps with breathing). The assessment failed to include Oxygen and the name and phone number of the durable medical equipment company was blank. The clinical record revealed a physician’s order dated 04/08/2023 for nursing 1 time per week for 9 weeks, Physical and Occupational therapy to evaluate and treat signed by the DON. The comprehensive assessment failed to include PT and OT evaluations. The clinical record revealed a PT evaluation completed on 04/10/2023 which documented Patient 2 had a wound to his right anterior forearm just inferior to the elbow from a fall yesterday where he landed on an oxygen tank. Record review revealed no documentation of nursing visits by LVN C 04/14/2023, 04/19/2023, 04/26/2023, 05/17/2023, and 05/24/2023. A home visit was made on 07/24/23 at 12:39 AM with Patient 2. The surveyor asked if the patient was on oxygen. The patient stated yes and described use of a liquid oxygen system with a portable tank for travel to appointments. The surveyor asked if the patient had trouble with his breathing and Patient 2 stated he had asthma and the rental he lived in wasn’t good for his breathing problems. The surveyor asked if Patient 2 had physical and occupations therapy services. Patient 2 stated he had physical therapy and had one OT visit and wanted to save OT for after his pending rotator cuff repair surgery. The surveyor asked who supplied the client with oxygen. Patient 2 stated he wasn’t sure but it might be on the equipment and the patient wanted a different kind of oxygen due to the electricity use of the current older equipment. The surveyor asked about nursing visits. Patient 2 stated he had weekly visits by LVN C in April and May and then he didn’t know what happened to the nurse. Review of the clinical record for Patient 3 on 07/21/2023 revealed a start of care date of 04/08/2023. The clinical record revealed no current plan of care for the care that began on 06/06/2023. The clinical record revealed an assessment dated 06/02/23 which was incomplete and failed to contain RN A’s signature. The assessment dated 06/02/23 was mostly blank from pages 2 to 8 of the 10-page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. Record review revealed no documentation of nursing visits by LVN C 04/14/2023, 04/19/2023, 04/26/2023, 05/03/2023, 05/10/2023, 05/17/2023, and 05/24/2023. A home visit was made on 07/24/23 at 1:15 PM with Patient 3. The surveyor observed the home folder provided by the agency during the home visit. The folder contained vital signs documented weekly by LVN C in April and May 2023 and then LVN A in June. The surveyor asked Patient 3’s spouse how often nurses came to see Patient 3. Patient 3’s spouse stated LVN C visited them weekly for a couple of months, then LVN C stopped coming, and then Patient 3 had LVN A, who also came every week. The surveyor asked what health problems Client 3 had. Client 3’s spouse stated Client 3 had Diabetes (chronic blood sugar metabolism disorder), a rare brain disorder called Moya Moya (causes dementia and bleeding in the brain), cirrhosis of the liver (impaired liver function due to scarring), and was losing too much weight. Review of Patient 5’s clinical record on 07/20/2023 revealed comprehensive assessments dated 04/27/23 and 06/26/23 which were incomplete and failed to contain RN A’s signature. The assessment dated 04/27/23 was mostly blank from pages 2 to 8 of the 10 page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. Neither of the assessments contained weights and blood sugars for the patient whose primary diagnosis on the plan of care dated 01/02/2023 to 03/02/2023 was Heart Failure (disease of the heart rendering the heart unable to pump enough blood to meet the bodies’ needs) , and whose other diagnoses were Chronic kidney disease, stage 4 (severe impairment of the kidneys), and Type 2 Diabetes (blood sugar disorder). Review of visit notes by LVN A dated 05/04/2023, 05/10/2023, 05/17/2023, 05/24/2023, 05/31/2023, 06/07/2023, 06/13/2023, and 06/20/2023 documented “fall reported last Friday, client is sore” on each of these visit notes. Review of Patient 6’s clinical record on 07/21/2023 revealed comprehensive assessment dated 06/15/23 which was incomplete and failed to contain RN A’s signature. The assessment dated 06/15/23 was mostly blank from pages 2 to 8 of the 10- page document. Key areas such as diagnoses, risk assessment, risks for hospitalization, prognosis, psychosocial assessment, sensory, pain, and integumentary status, pressure sore risk assessment, cardiac, respiratory, elimination, neuro/emotional/behavioral, and functional status were all blank. Additional blank areas included functional assessment items M1810 to M 1860, Self-Care abilities GG 0130 and GG017 items, endocrine, nutrition, medication status and medication administration. Review of nurses notes for Patient 6 by LVN A dated 06/22/2023 and 06/29/2023 revealed the nurse documented providing wound care to Patient 6’s diabetic foot ulcer, and on 07/06/2023 LVN A documented a different wound care and the application of a compression dressing. The surveyor attempted to interview LVN C on 07/25/2023 at 2:31PM and sent a text message requesting a call back on 07/25/2023. LVN C did not return the call. A telephone interview was conducted on 07/25/23 at 2:51 PM with LVN A. The surveyor reviewed the LVN notes for Patient 5 and asked if the fall documentation was accurate. LVN A stated it was not accurate and the nurse was “transferring from previous notes and I didn’t do a good edit.” The surveyor asked about Patient 6 and the documentation of wound care on 06/22/2023 and 06/29/2023. The LVN stated the notes were not accurate and the patient had no wounds and the nurse stated they did not apply a compression dressing. A telephone interview was conducted with RN A on 07/25/2023 at 3:57 PM. The surveyor asked why there was no Asthma diagnosis, no PT and OT evaluations, and no oxygen and oxygen provider on Patient 2’s start of care assessment. RN A stated they had never seen Patient 2 wear oxygen and she had “missed it.” RN A stated the agency outsources PT and OT and she did not coordinate with them. The RN said that they only see the agency’s patient’s every 2 months for the OASIS assessments and they do not case manage the patients care. The surveyor asked reviewed the incomplete assessments found during the record review and asked why they were not completed. RN A stated they were “up to too much” and they “almost have everything up to date. I have been driving 178 miles a day.” The surveyor asked why the assessments were partially completed. The RN stated they opened the assessments and put vitals in and then saved them to finish them later. The surveyor asked about the missing plans of care. RN A stated the plans of care were not generated until the nurse completed the comprehensive assessments. The surveyor asked about wound care orders for Patient 6. RN A stated she didn’t think the patient had a wound. The surveyor asked why LVN A would document wound care orders on visit notes dated 06/22/2023 and 06/29/2023. RN A reviewed the record and explained the nurses can pull old information from previous care episodes over to the current note or assessment. A telephone interview was attempted with the DON on 07/25/2023 at 4:42 PM and 07/27/2023 at 4:06 PM. The DON did not return the calls. A telephone interview was conducted with the Alternate Clinical Director on 07/25/2023 at 5:41 PM. The surveyor asked the Alternate Clinical Director about the missing assessments and plans of care for Patients 1,2,3,5 and 6). The Alternate Clinical Director stated they didn’t work with Patients 1,2, 3, 5, and 6 and could not answer the questions. An interview was conducted on 07/27/2023 at 2:15PM with the Administrator and Alternate Administrator. The surveyor reviewed the findings of the record reviews review and home visits with Patient’s 1, 2, and 3 and the record reviews for Patient’s 5 and 6. The surveyor asked about the assessments that were not complete. The Administrator stated RN A worked with the patients the surveyor had chosen and not the Alternate Clinical Director. The Administrator stated RN A is good with the patients and works at a hospital full time too and usually gets all her documentation done by the end of the month. The Administrator stated: “changing the DON is the thing I need to do because she hasn’t been doing her job.” The surveyor asked how long the Administrator felt the DON hasn’t been doing her job. The Administrator stated the DON was “also working in a hospital and has been the DON since 2017.” The surveyor asked about the LVN notes that were incomplete for Patients 2 and 3. The Administrator stated LVN C has been fired for a month. The Administrator stated he has not been able to get ahold of him and he has three paychecks for 6 weeks work waiting in the office for him to pick up. The Administrator stated LVN C normally finished by the end of the month and he will finish the notes before coming in the pick up his check. Agency policy and procedures titled: Patient / Client Assessment Guidelines PE 2 dated 03/01/2019 read in part: The Agency will use and adhere to a defined comprehensive assessment in order to identify the patient’s/client’s needs for home care and that meets the patient’s/client’s medical, nursing, rehabilitative, social and discharge planning needs. Agency policy and procedures titled: TIMELINES IM.7 dated 01/01/2018 read in part: Purpose -To establish timely parameters for all medical record information…. A Registered Nurse … will complete the Initial Comprehensive Assessment no later than five (5) days after the start of care (SOC) for all patient’s/ client in a licensed and certified agency…Daily progress notes with correlating time sheets are turned in within a maximum of seven (7) calendar days...All clinical and progress notes will be written the day service is rendered…All medical record information will be incorporated into the patient’s/client's medical record within fourteen (14) working days. Agency policy titled: MEDICAL RECORD CONTENT IM.5 dated 02/01/2019 read in part: PURPOSE -To ensure each medical record, whether paper, electronic or combination, contains complete information which identifies the patient/client, describes problems and needs of the patient/client, justifies patient/client care, and accurately describes care provided… Agency policy titled: RESPONSIBILITIES OF THE ADMINISTRATOR LD.5 dated 01/13/2018 read in part: PURPOSE - To define the responsibilities of the Administrator to ensure Agency compliance with applicable federal, state and local laws and regulations related to the health and safety of patients/clients. POLICY The agency Administrator will assume authority and responsibility for day-to-day operations of the agency… The Administrator will be responsible for implementing and supervising the administrative policies and operations of the agency and for administratively supervising the provision of all services to patients/clients on a day-to-day basis… The Agency defines the responsibilities of the Administrator to include: …Ensuring documentation of services is accurate and timely.