Every finding on record at Covenant Care at Home

The following reflects the findings of the California Department of Public Health during an EMERGENCY PREPAREDNESS SURVEY conducted 3/24/26 through 3/26/26. The agency reported 920 unduplicated annual admissions. The sample size was 17, and 7 home visits were conducted. The home health agency was found to be in compliance with 42 CFR, part 418.102 for Emergency Preparedness.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 3/24/26 through 3/26/26. The agency reported 920 unduplicated annual admissions. The sample size was 17, and 7 home visits were conducted.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS, a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services, (CMS)) data was transmitted within 30 days of completing the OASIS data sets. This failure created the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA. Findings: During a review on 3/26/26 of the agency’s OASIS validation reports dated February 2026, the following was identified: The agency’s “Oasis Agency Final Validation,” report submission date of 2/20/26 at 4:58 PM indicated, eight of eight data sets were submitted more than 30 days from the assessment completion date. The agency’s “Oasis Agency Final Validation,” report submission date of 2/20/26 at 4:59 PM indicated, two of two data sets were submitted more than 30 days from the assessment completion date. During a concurrent interview and record review on 3/26/26 at 1:42 PM with the Medical Coder (MC), the two Oasis Validation reports dated 2/20/26 were reviewed. The MC confirmed a total of ten data sets were submitted more than 30 days from the completion date for the two reports dated 2/20/26. The MC stated she exported data sets three times per week and usually monitored them to ensure the submissions were all on track. The MC further stated the ten data sets were exported from the agency’s electronic health record on January 16, but that file was missed when she uploaded all her files for submission. The MC stated she became aware of the omission when the billing agent contacted her on 2/19/26. During a review of the agency’s policy titled, “OASIS DATA TRANSMISSION,” revised 11/24, the policy indicated, “…The organization will adhere to all OASIS requirements as outlined in the Medicare Conditions of Participation…The organization may take up to thirty (30) calendar days after the date of completion…to enter the OASIS data into their computers using internet Quality Improvement Evaluation System (iQIES) [web based system used to collect analyze and report patient and provider data for Medicare and Medicaid programs]…The validation logs in iQIES will be reviewed for accuracy purposes and kept for twelve (12) months…”

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 facility failed to ensure medication safety for four out of seventeen sampled patients (Patient 1, Patient 2, Patient 4, and Patient 5) when Patient 1, Patient 2, Patient 4, and Patient 5 had medications that were not verified during the comprehensive review. This failure had the potential to result in unsafe medication use and decreased well-being for Patient 1, Patient 2, Patient 4, and Patient 5. Findings: Findings: A review of Patient 5’s clinical document titled, “Patient Information,” indicated, Patient 5 was admitted to the agency with diagnoses which included atherosclerotic heart disease (build up of plaque in the walls of arteries, can lead to heart attack and stroke). During a review of Patient 5’s clinical document titled, “Charts/Clinical Notes,” dated 3/18/26, the document indicated, “…Discipline: PT-Physical Therapy …VS [vital signs] taken and BP [blood pressure] on the low end for pt [patient]…” During a review of Patient 5’s clinical document titled, “Charts/Clinical Notes,” dated 3/20/26, the document indicated, “…Discipline: PT-Physical Therapy…VS taken at start of visit and BP low…” During a concurrent interview and record review during an onsite assisted living facility (ALF) visit, on 3/25/26 at 2:09 PM with Patient 5 and the Physical Therapist (PT), Patient 5’s agency medication list was compared to the ALF medication list. The PT confirmed two medications, nifedipine (medication used to treat high blood pressure) and furosemide (medication used for heart disease, can cause low blood pressure), were included on the ALF list but not on the agency list. Patient 5 confirmed she took both nifedipine and furosemide every morning. During an interview on 3/25/26 at 3:03 PM with the PT, the PT stated it was her responsibility to check with the ALF regarding Patient 5’s medications. The PT confirmed she was not aware Patient 5 was prescribed nifedipine and furosemide. During a concurrent interview and record review on 3/26/26 at 1:10 PM with the Clinical Director (CD), Patient 5’s clinical notes and medication lists were reviewed. The CD confirmed Patient 5’s clinical notes indicated Patient 5’s BP had been low on 3/18/26 and 3/20/26. The CD confirmed Patient 5’s medication list from the ALF titled “Physician Order Review,” indicated furosemide was ordered on 2/5/26 and nifedipine was ordered on 3/1/26 and neither medication was listed on the agency’s medication list. The CD stated the furosemide should have been on the agency’s medication list from Patient 5’s start of care date of 2/6/26. The CD further stated there had been 11 PT visits with Patient 5 since the nifedipine had been ordered on 3/1/26 and the medication change should have been noted during those visits. The CD stated the potential side effects of nifedipine and furosemide included dizziness and falls which could lead to fractured limbs. A review of a facility policy titled “Medication Profile,” revised 11/2024, indicated, “…Purpose…To define the use of the medication profile in evaluating a patient’s medication regimen …Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…Procedure…1. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, drug classification, date prescribed…dose, strength, route, frequency, date and time of administration, and any food or drug allergies…2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication…A. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions…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. This includes, but will not be limited to…A. Using the medication profile to evaluate the use of medications in the home setting…” 1.A review of Patient 4’s “Patient Information Sheet,” indicated that Patient 4 started care in 2025 with diagnoses which included Acute Respiratory Failure (a condition caused by the lungs’ failure to oxygenate the blood), Hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high. This causes the heart to work harder to pump blood), and Sciatica (pain and numbness that travels from the lower back down one leg caused by compression of the sciatic nerve [a long nerve in the body that extends from the buttocks down each leg to the foot]). A review of Patient 4’s “Medication List,” on 3/24/26 at 3:00 p.m. indicated “…Acetaminophen (medication prescribed for pain) By Mouth 325 MG (unit of measure) 2 tab q (every) 4h (hours) po (orally) PRN (as needed) mild pain…” A review of Patient 4’s “Medication List,” on 3/24/26 at 3:00 p.m. indicated, “…Albuterol Sulfate HFA Inhaler Aerosol Solution (a medication prescribed to assist with breathing) 108…MCG/ACT (unit of measure) 2 puffs prn Inhaler (a portable device to administer a drug which is to be breathed in) …” A review of Patient 4’s “Medication List,” on 3/24/26 at 3:00 p.m. indicated, “…FeroSul (a supplement prescribed to increase iron levels in the body) By Mouth Tablet 325…MG 1 tab bid (twice a day) po…” During an interview with Licensed Nurse (LN) 1 on 3/25/26 at 12:00 p.m., LN 1 stated that she visited Patient 4 for a vital signs (an assessment of the body’s basic functions including body temperature, heart rate, blood pressure, and respiratory rate [the number of breath taken in one minute]) check and blood specimen (a procedure where a needle is used to take blood from a vein) for laboratory testing. During an observation and concurrent interview with Patient 4 and LN 1 at Patient 4’s home on 3/25/26 at 12:07 p.m., LN 1 reviewed the medication list and medication containers with Patient 4. During the review, Patient 4 stated that she used hydrocodone (Norco, a medication prescribed for pain) for Sciatica for the past three months. Patient 4 had a prescription bottle of Norco showing a refill date of 3/4/26. Patient 4 stated that she also had Acetaminophen 500 mg over-the-counter (medication that can be purchased without a prescription) tablets, but that she had not been taking them because they did not work. Patient 4 also stated that she took Ferrous Sulfate 324 mg E.C. tablets (a supplement prescribed to increase iron levels in the body that is covered with a substance that releases the iron in the small intestine [part of the bowel between the stomach and the large intestine] rather than the stomach). Further, Patient 4 asked how often she should take the Albuterol inhaler, and LN 1 stated that Patient 4 should use the inhaler as needed. During an interview and concurrent review of Patient 4’s “Medication List,” with LN 1 on 3/25/26 at 1:07 p.m., LN 1 confirmed that the “Medication List,” for Patient 4 was the most recent list of prescribed medications the agency had. LN 1 confirmed that the Norco that Patient 4 stated that she had been taking for pain was not on the “Medication List.” LN 1 confirmed that the Ferrous Sulfate 324 mg E.C tablets that Patient 4 stated that she was taking were not on the medication list. LN 1 confirmed that the Acetaminophen 500 mg tablets that Patient 4 had at her home were not on the medication list. LN 1 stated that the risk of Patient 4 taking a medication that was not on the “Medication List” was drug interaction (refers to a change in the way a drug acts in the body when taken with other drugs, supplements, food, or certain medical conditions). LN 1 stated that since Norco also contained Acetaminophen, taking Norco put Patient 4 at risk of taking too much Acetaminophen. LN 1 stated that taking too much Acetaminophen could cause liver problems. LN 1 stated that the Albuterol inhaler prescribed for Patient 4 should have a time frame for use. LN 1 stated that the risk of not having a time frame for use was that Patient 4 could take too much, causing an overdose (taking a higher drug dose than the body can handle) which can cause a serious health risk for Patient 4. During an interview and concurrent record review of Patient 4’s “Medication List,” on 3/26/26 at 1:22 p.m. with the facility Clinical Director (CD), the CD stated that the expectation was that the patients’ medication lists were being reviewed and updated during home visits. The CD acknowledged that Patient 4’s Albuterol inhaler order should have a time frame for administration (how often). The CD stated that if the Albuterol inhaler was taken incorrectly, there was a risk of adverse effects (including heart rate increase, dizziness and fall, risk of bleeding if on anticoagulants). The CD stated that she considered this a missed opportunity since January 26, 2026. The CD stated that the Acetaminophen was ordered regular strength (325 mg) tablets, and Patient 4 had Extra Strength (500 mg) tablets. The CD stated that there was a risk of liver failure (occurs when the liver begins to lose its ability to filter blood, produce bile for fat digestion, clear harmful substances from the body, and regulates glucose, protein, and cholesterol levels) for Patient 4 if she took too much Acetaminophen. The CD confirmed that Norco was not on the list of current medications for Patient 4. The CD stated that the risk of Patient 4 taking Norco included interactions with other prescribed medications, overdose with Acetaminophen since Norco contained Acetaminophen, falls, and severe constipation. The CD confirmed that since Patient 4 had the prescription for Norco refilled on 3/4/26, went to hospital on 3/6/26, and resumed services on 3/12/26, the medication discrepancy should have been caught when services resumed. The CD confirmed that FeroSul 325 mg tablets were on the physician order for Patient 4. The CD acknowledged that Patient 4 had Ferrous Sulfate 324 mg E.C tablets at home. The CD stated that the risk for Patient 4 was iron interaction with other medications, and constipation. The CD confirmed that there were missed opportunities to correct the discrepancies with Patient 4’s medications on each visit. A review of a facility policy and procedure (P&P) titled, “Medication Profile,” revised November 2024, the P&P indicated, “…Purpose…To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals…Policy…Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record…Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…Procedure…1. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, drug classification, date prescribed…dose, strength, route, frequency, date and time of administration, and any food or drug allergies…2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication…A. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions…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. This includes, but will not be limited to…A. Using the medication profile to evaluate the use of medications in the home setting…” Findings: 1. A review of Patient 1’s clinical document titled, “Patient Information,” indicated, Patient 1 was admitted to the home health agency (HHA) with diagnoses which included, acute respiratory failure (a sudden, life-threatening condition where the respiratory system [lungs, airways] fail to oxygenate blood properly) emphysema (a chronic progressive lung disease that causes severe shortness of breath) and chronic obstructive pulmonary disease (COPD -a progressive, long-term lung disease that makes breathing difficult by damaging air sacs and inflaming airways). During a concurrent observation, interview, and record review on 3/25/26 at 9:32 AM, at Patient 1’s home, Patient 1’s medication bottles were reviewed with Licensed Nurse (LN) 2. The following discrepancies were reviewed and compared to what medications Patient 1 was taking versus what the home health agency’s document titled, “Medication List,” dated 3/25/26 indicated: a. Spiriva Respimat Inhaler Aerosol Solution (long-acting inhaler used to open the airways) 2.5 mcg (mcg -micrograms, a unit of measure) take 2 puffs at bedtime. -Patient 1 and family member (FM) 1 confirmed use: 1 puff at lunch time. Patient 1 stated he has been taking this medication since 2/24/26. Confirmed with LN 2 that the medication usage did not match the HHA's medication list. b. Vitamin B-12 (vitamin supplement) 500 mcg, 1 tab (tablet) PO (PO per os -by mouth) daily. -Patient 1 and FM 1 confirmed use: Vitamin B-12 1000 mcg, daily, as observed on the bottle and had been taking since last year. Confirmed with LN 2 that the dose did not match the HHA's medication list. c. Olopatadine HCl (hydrochloride) Ophthalmic Solution (eye drops) 0.1%, 1 gtt (drop) bid (twice daily). -Patient 1 and FM 1 confirmed he had not used the eye drops since February 2025 and that the eye drops were not in the home or available for use. Confirmed with LN 2 that the medication was still listed as in use by the HHA's medication list. d. Cozaar (blood pressure [BP] medication) 100 mg (mg -milligrams a unit of measure) 1 tab by mouth daily. -Patient 1 and FM 1 confirmed he stopped taking this medication on 1/31/26. Confirmed with LN 2 the medication was still listed as in use by the HHA's medication list. e. Furosemide (Blood pressure [BP] medication) 20 mg, 1 tab prn (as needed) po. PRN for swelling. -Patient 1 and FM 1 confirmed he only took the medication if he had two (2) pound or more weight gain in a 24-hour period, as instructed by his doctor and on the label of the medication. FM 1 confirmed medication changed on 2/23/26. Confirmed with LN 2 that the frequency and directions for use were missing on the HHA medication list. f. FeroSul (Iron supplement) 325 mg (65 Fe -Iron dose), 1 tab q (every) two days po. -Patient 1 and FM 1 confirmed he took 1 tablet by mouth every day since January 2026. Confirmed with LN 2 that the frequency did not match on the HHA medication list. g. Combivent Respimat Inhaler Aerosol Solution (Inhaler spray used for long term maintenance of emphysema and COPD) 20-100 mcg, 1 puff prn. -Patient 1 and FM 1 confirmed he does not have the medication and never took the medication. Confirmed with LN 2 that the medication was listed as currently in use on the HHA medication list. During an interview on 3/25/26 at 10:04 AM with LN 2, LN 2 confirmed the HHA’s medication list differed from Patient 1’s usage as follows: Spiriva inhaler usage did not match, the B12 dose was incorrect, the patient stopped Cozaar and the eye drops, Patient 1 was taking the iron supplement daily, the Furosemide did not indicate a frequency for PRN use, and did not indicate to be used with 2 pound weight gain, and Patient 1 never used the Combivent Respimat inhaler. LN 2 stated it was important to have a frequency listed for medication use so the patient did not over medicate. LN 2 further stated it was important to update and observe the medication bottles compared to their medication list to make sure everything matched. LN 2 explained it was important so the HHA could monitor side effects and educate the patient on the correct use. LN 2 stated the risk to the patient was the patient could take too much of a medication or not enough and cause the patient to get sick. LN 2 further stated their medication list instructions should match the patients instructions so the HHA could educate the patient and family on correct use and when to hold or give a medication that was supposed to be taken as needed. LN 2 explained the medications should have been updated on 2/25/26 when the patient was discharged from a short hospital stay, or at least once a week with a registered nurse (RN). 2. A review of Patient 2’s clinical document titled, “Home Health Certification and Plan of Care ,” (POC) dated 3/11/26, indicated, Patient 2 was admitted to the home health agency (HHA) with diagnoses which included, cellulitis of right lower limb (serious infection of the deep skin and tissues), and diabetes type two (chronic high amount of sugar in the blood where the body fails to produce enough insulin to reduce sugar), chronic kidney disease (a condition where the kidney’s are damaged and cannot filter blood properly), major depressive disorder (a serious mental health condition with persistent sadness, lasting at least two weeks) and chronic diastolic heart failure (occurs when a stiff left ventricle in the heart cannot fill properly with blood). During a concurrent observation, interview and record review on 3/25/26 at 12:29 PM, in Patient 2’s home, Patient 2’s medication bottles were reviewed with LN 3. The bottles were observed organized in 3 drawers all labeled. The following discrepancies were reviewed and compared to the medications Patient 2 was taking versus what the home health agency’s document “Medication List,” dated 3/25/26 indicated: a. Melatonin (sleep hormone) 12 mg, 1-tab hs (at bedtime) po. -Patient 2 confirmed he took 10 mg and the bottle was reviewed and confirmed with LN 3, indicating 10 mg. Patient 2 stated he had been taking the same dose for several years. b. Red Grape Resveratrol (a natural antioxidant that is known to fight aging) 100 mg, 1 cap (capsule) daily. -Patient 2 confirmed he took 429 mg daily and the bottle was reviewed and confirmed with LN 3. Patient 2 stated he had been taking the same dose for several years. c. Metoprolol Succinate ER 50 mg (extended-release blood pressure medication) 1-tab po bid (twice daily). -Patient 2 confirmed he takes 25 mg tab twice daily, confirmed bottle with LN 3 and the dose was listed as 25 mg. Patient 2 stated he had been on this dose for at least one year. During a further review of Patient 2’s medication bottles, it was observed by LN 3 that Patient 2 was also taking the following medications. LN 3 confirmed the medications were not documented on Patient 2’s clinical document, “Medication List,” dated 3/25/26: -Irbesartan (prescription blood pressure medication) 300 mg, 1-tab po at bedtime. Patient 2 stated he had been taking for several years. -Immune Senescence Protection (over the counter supplement) that contains, calcium carbonate 175 mg, reishi mushroom extract 980 mg and 32.5 mg of caffeine. Patient 2 stated he takes 2 tablets daily and has since January 2025. -Mag SRT (magnesium and other vitamin supplements) which contain B6, folate, B12, and magnesium malate 500 mg. Patient 2 confirmed he took 1 tablet a day and had since January 2025. -One a Day Men’s 50+ Multivitamin (multiple vitamins and supplements, combined in one tablet, which also contain magnesium, calcium, folate, B6 and B12 vitamins), 1 tab daily. Patient 2 confirmed he had been taking it for several years. -Fish oil supplement (supplement used to support heart, brain and joint health), 2 caps by mouth daily. Patient 2 confirmed he had been taking it for several years. -Vitamin C (vitamin supplement) 500 mg, 1 tab once daily. Patient 2 confirmed he had been taking it for several years. -Vitamin D3 (vitamin supplement) 2000 iu (international units), 1 tab by mouth twice daily. Patient 2 confirmed he had been taking it for several years. -Ashwagandha supplement (stress and cortisol reducing supplement) no dose listed, 1 tab my mouth at bedtime. Patient 2 confirmed he had been taking it for several years. Patient 2 further stated the HHA had not previously asked to see his medication bottles. Patient 2 further stated he kept all prescription and over the counter medications together. During an interview on 3/25/26 at 12:49 PM, with LN 3, LN 3 confirmed she had no idea of the additional medications Patient 2 was taking. LN 3 stated that the bottles should have been observed and confirmed when Patient 2 was admitted to the HHA and during follow-up visits. LN 3 confirmed that several supplements and vitamins were duplicated in different tablet forms and that could put Patient 2 at serious risk of overmedicating and complicating Patient 2’s medical conditions. LN 3 explained it was important to document every medication and supplement the patient took because the HHA's medical record system had a drug interaction and duplicate therapy program that alerted the nurses of serious drug conflicts. LN 3 explained a complete medication reconciliation should be done on admission and as needed, and that it should include reviewing the bottles. During a concurrent interview and record review on 3/26/26 at 11:30 AM, with the Clinical Director (CD), the CD reviewed Patient 1 and Patient 2’s medical record and comprehensive visits by the LN’s. The CD explained that a comprehensive visit was any visit where a LN saw the patient. The CD stated it was important that a medication reconciliation was done on the initial or admission assessment, after hospitalization/readmission, and at each comprehensive visit. The CD further explained it was her expectation that during each LN visit the patients’ medication lists were compared to the medication bottles. After further review of Patient 1’s medical record and comprehensive visits, the CD confirmed there were 15 missed opportunities for the HHA to update and reconcile Patient 1’s medications. The CD further confirmed that Patient 2 had 7 missed opportunities for the HHA to update and reconcile Patient 2’s medications. The CD explained that the risk to the patients was not knowing if there could be a major drug interaction. The CD added that reviewing the medications with the patients during the visits could prevent the patient from being under medicated, overmedicated, which could lead to falls, bleeding, and other serious health complications. A review of facility policy and procedure (P&P) titled, "Care Planning Process," revised November 2024, indicated, "...The patient plan of care [POC] will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient...Individualized Plan Of Care: The patient-specific clinical plan of care includes...M. Medication and treatments...All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including...Clinical drug monitoring...3. Based on assessment and conclusions, the plan of care will include...K. All medications...17. The organization shall provide the patient and caregiver with a copy of written instructions outlining...B. Patient medication schedule/instructions, including medication name, dosage and frequency..." A review of facility P&P titled, "Medication Monitoring," revised November 2024, indicated, "...Ongoing patient medication monitoring will use a collaborative approach between clinicians, physicians, pharmacists, patients, and families/caregivers...medication monitoring will be used to improve the patient's medication regime. The ongoing monitoring will occur in accordance with the established goals of therapy to be used to: 1. Evaluate the continued use of a medication in the current regiment. 2. Evaluate patient adherence to the prescribed medication regimen...The clinician will assess the effect of medications on the patient. The assessment will identify potential contraindications, drug interactions, duplicative drug therapy, significant adverse reactions...The clinical effects of medications will be assessed through direct observation during home visits, review of assessment information...The information obtained through patient medication monitoring will be documented in the patient's clinic record..."

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for two of seventeen sampled patients (Patient 3 and Patient 4), when: Hand hygiene (the process of cleaning hands with soap and water or using alcohol-based rubs (hand sanitizer) to prevent the spread of germs) was not performed between glove changes for Patient 3 and Patient 4; and,Vital signs equipment (hand held equipment used to check a patients blood pressure, pulse, heart rate, temperature, and oxygen levels) was not cleaned after use and before putting back into a canvas bag; and,Wash basins were not cleaned per manufacturer guidelines for Patient 3.These failures had the potential to spread infection and cause health problems for Patient 3 and Patient 4. 1b. During an observation on 3/25/26 at 1:36 PM, in Patient 3’s home, with Home Health Aide (HHA) 1, HHA 1 was observed providing a bed bath, grooming, and changing of Patient 3’s bed linen. During the home visit it was observed that HHA 1 changed her gloves during the bed bath three (3) times, once after removing dirty clothes and linen, second washing the front of Patient 3, and finally after completing peri care (cleaning of the genital and anal areas), HHA 1 did not perform hand hygiene (washing hands with soap and water or an alcohol-based hand sanitizer) after removing dirty gloves and before putting on clean gloves. During an interview on 3/25/26 at 2:07 PM, outside of Patient 3’s home, HHA 1 confirmed she did not perform hand hygiene after removing her gloves multiple times while providing care to Patient 3. The HHA 1 stated she was nervous being observed and forgot to complete hand hygiene between multiple glove changes. HHA 1 stated hand hygiene before putting on clean gloves and after removing dirty gloves was expected and part of her infection control (a set of policies, procedures, and practices designed to prevent the spread of infections) training. HHA 1 stated it was important to complete hand hygiene after dirty glove removal and before putting on clean gloves because her hands could have been contaminated and she could cross contaminate (unintentional transfer of harmful germs, bacteria or viruses) the clean gloves and transfer something to Patient 3. HHA 1 further stated the risk to Patient 3 for improper hand hygiene was infection or illness. 2. During an observation on 3/25/26 at 1:13 PM, in Patient 3’s home, HHA 1 was observed taking a blood pressure cuff (an inflatable sleeve wrapped around the upper arm to measure blood pressure), a pulse oximeter (a device that clips onto the end of a fingertip to measure the percent of oxygen in the blood and the heart rate), and a thermometer (device used to accurately measure human body temperature -specific kind that is held against the forehead) out of a small compartment in her canvas bag to measure the vital signs of Patient 3. HHA 1 was observed placing the cuff on Patient 3’s left arm, the pulse oximeter on Patient 3’s index finger and touching the thermometer to Patient 3’s forehead. When HHA 1 completed the vitals signs for Patient 3, HHA 1 was observed placing the blood pressure cuff, pulse oximeter and the thermometer back into the same small compartment of her canvas bag without sanitizing the equipment. During an interview on 3/25/26 at 2:07 PM, outside of Patient 3’s home, HHA 1 was observed placing her canvas bag in the trunk of her car. HHA 1 confirmed she placed the blood pressure cuff, pulse oximeter and thermometer back into the same compartment she removed them from without sanitizing them. HHA 1 further stated she usually sanitized the equipment after she left the patients home. HHA 1 added that she puts the blood pressure cuff, pulse oximeter and thermometer back into the same small compartment of her canvas bag after she sanitized them. HHA 1 stated it did not occur to her that she would contaminate the sanitized equipment when she placed the cleaned equipment back into the same used dirty compartment of the canvas bag. The HHA 1 further stated she did not use any type of protective barrier in the compartments of her canvas bag. The HHA 1 explained the risk to the patients when she used contaminated equipment on them, could be spreading germs from one patient to another. 3. During an observation on 3/25/26 at 2:05 PM, in Patient 3’s home, HHA 1 was observed cleaning two gray wash basin’s used to bathe Patient 3. HHA 1 was observed taking one lemon scented disinfectant wipe from the container and wiped the basin once in a circular motion. HHA 1 was observed taking a paper towel and wiped the basin dry immediately after it was wiped with the disinfectant wipe. HHA 1 was observed taking another disinfectant wipe from the container and wiped the second gray basin once in a circular motion. HHA 1 was observed immediately using the same paper towel to dry the second basin. During an interview on 3/25/26 at 2:07 PM, outside of Patient 3’s home, HHA 1 confirmed she wiped each gray bath basin with a disinfectant wipe and immediately dried them with a paper towel. During a review on 3/25/26 at 2:10 PM, the instructions for use as indicated on the back of the disinfectant wipe container was reviewed with HHA 1. The label indicated, “…To clean and remove allergens. Wipe surface clean with this product. Let air dry…To spot sanitize soft surfaces…Wipe surface; use enough wipes for treated surfaces to remain visibly wet for 4 minutes. Allow to air dry…”. HHA 1 stated she was not aware of the air-dry requirement or the 4 minutes wet contact time to disinfect. https://www.clorox.com/products/clorox-disinfecting-wipes/ During an interview on 3/26/26 at 2 PM with the Clinical Supervisor (CS), the CS stated it was her expectation for hand hygiene to be completed before putting on clean gloves and after removing dirty gloves, which was standard precautions. The CS further stated the gray wash basin's should have been cleansed and wet for 4 minutes per the manufacturer's instructions for use and allowed to air dry instead of being wiped dry with a paper towel. The CS explained this does not meet her expectation for quality infection control and prevention. The CS added she expected the vitals equipment to be disinfected per the instructions of the disinfectant wipe label with a wet contact time of 4 minutes, and air dried prior to being put back in the equipment bag and before leaving the patients home. The CS explained the risk to the patient was cross contamination, illness and worsening of patients medical conditions. A review of a facility policy and procedure (P&P) titled, “Hand Hygiene,” revised January 2017, the P&P indicated, “…Purpose…To prevent cross-contamination and home care-acquired infections…Policy…Personnel providing care in the home setting will regularly wash their hands per the most recently published CDC (Centers for Disease Control and Prevention) regulations and guidelines for hand hygiene in healthcare settings…When hands are visibly dirty…they should be washed with either a non-antimicrobial (a substance that kills germs or prevents growth of germs and spread of illness) or antimicrobial soap and water. When hands are not visibly soiled, they should be washed using an alcohol-based hand rub…An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water…Procedure…Hand decontamination with an alcohol-based hand rub…3. Hand decontamination using an alcohol-based hand rub should be performed…A. Before having direct contact with patients…C. After having contact with a patient’s intact skin…E. When moving from a contaminated (containing germs) body site to a clean body site during patient care…F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient…G. After removing gloves…Hand Washing with Soap and Water…6. Hand washing using soap and water should be performed…C. When hands are visibly dirty or contaminated…E. Before and after treating a patient…” A review of the facility policy and procedure (P&P) titled, “Bag Technique,” revised, November 2024, indicated, “…To describe the procedure for maintaining a clean nursing bag…and preventing cross-contamination…4. The bag will contain a designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment) …When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag…” Findings: 1.A review of Patient 4’s “Patient Information Sheet,” indicated that Patient 4 started care in 2025 with diagnoses which included Acute Respiratory Failure (a condition caused by the lungs’ failure to oxygenate the blood), Hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high. This causes the heart to work harder to pump blood), and Sciatica (pain and numbness that travels from the lower back down one leg caused by compression of the sciatic nerve [a long nerve in the body that extends from the buttocks down each leg to the foot]). A review of Patient 4’s “Plan of Care Report,” on 3/24/26 indicated, “…Orders for …Treatments…Assess…vital signs…Venipuncture (a procedure in which a needle is used to take blood from a vein) …” During an interview with Licensed Nurse (LN) 1 on 3/25/26 at 12:00 p.m., LN 1 stated that she visited Patient 4 for a vital signs (an assessment of the body’s basic functions including body temperature, heart rate, blood pressure, and respiratory rate [the number of breath taken in one minute]) check and venipuncture to obtain blood for laboratory testing. During an observation with Patient 4 and LN 1 on 3/25/26 at 12:22 p.m. at Patient 4’s home, LN 1 told Patient 4 that she would obtain a blood specimen for testing. LN 1 performed hand hygiene and put on gloves. LN 1 touched Patient 4’s right arm for vein to use for blood specimen. LN 1 applied a tourniquet (a type of tightening device that stops blood flow to an arm or leg used to distend [swell or expand] veins to facilitate venipuncture) to Patient 4’s right arm and wiped Patient 4’s arm with an alcohol swab. LN 1 attempted venipuncture on Patient 4’s right arm to get the blood specimen but was unsuccessful. LN 1 discarded the used needle in a sharps disposal container (a rigid, puncture-resistant waste container specifically designed for the safe disposal of sharp medical instruments) and applied pressure to the puncture site on Patient 4’s right arm with a clean gauze pad while wearing gloves. LN 1 then removed the gloves and put paper tape over the gauze pad to keep it in place, then put on a second pair of gloves without cleaning her hands. LN 1 put a tourniquet on Patient 4’s left arm, cleaned the arm with an alcohol pad, and attempted venipuncture to get the blood specimen from Patient 4’s left arm but was again unsuccessful. LN 1 put a clean gauze pad over the puncture site on Patient 4’s left arm and secured the gauze pad with paper tape. LN 1 stated that she needed to get more supplies from her car and went to her car while wearing gloves. LN 1 returned a short time later with more supplies, and asked permission to make a third attempt to get the blood specimen. Patient 4 agreed to the third attempt, so LN 1 assessed Patient 4’s right wrist veins, cleaned the area with an alcohol swab, applied a tourniquet to Patient 4’s right arm and attempted venipuncture to get the blood specimen but was again unsuccessful. Patient 4 told LN 1 that staff had a difficult time obtaining a blood specimen from her veins. LN 1 told Patient 4 that she would notify the physician. LN 1 grabbed her tablet out of the canvas bag to document while wearing gloves, then placed the tablet back into the canvas bag, removed the gloves and cleaned her hands. During an interview with LN 1 on 3/25/26 at 1:08 p.m., LN 1 stated that the purpose of cleaning her hands was to prevent the spread of infection (the presence and growth of germs). LN 1 stated that she cleaned her hands between patents and when putting on and removing gloves. LN 1 acknowledged that she missed an opportunity to clean her hands when getting clean supplies from the trunk of her car. LN 1 acknowledged that she removed clean supplies from the clean container in the trunk of her car while wearing the gloves used during venipuncture. LN 1 stated that there was a risk that the clean supplies were contaminated (contained germs) when she touched the supplies while wearing the gloves used for venipuncture. LN 1 acknowledged that she missed an opportunity to clean her hands during venipuncture with Patient 4. LN 1 acknowledged that during venipuncture, she removed her gloves, applied gauze to the venipuncture site, then applied gloves without cleaning her hands. LN 1 acknowledged that she also missed an opportunity to clean her hands when typing a note on her tablet. LN 1 acknowledged that she grabbed the tablet from the canvas bag using the gloves she wore during the third venipuncture attempt, typed a note on the tablet, then put the tablet back into the canvas bag with the same gloves used during venipuncture. LN 1 stated that the risk of the missed opportunities for cleaning her hands was contamination (presence of germs). During an interview on 3/26/26 at 2:00 p.m. with the facility Clinical Supervisor (CS) and the Clinical Director (CD), the CS and the CD stated that their expectation for hand hygiene was that the clinical staff washed or sanitized their hands before putting on gloves and after removing gloves. The CS and the CD stated that hand hygiene was important to prevent cross-contamination (physical movement or transfer of harmful germs from one person, object, or place to another) to protect self, patients, and their families. The CS and the CD stated that their expectation is that hand hygiene was part of standard precautions (infection control and prevention practices that need to be done at all times, such as hand hygiene, to prevent the spread of germs). The CS and the CD stated that the risk of not performing hand hygiene during patient care included Illnesses caused by influenza, infections, and worsening of conditions. A review of a facility policy and procedure (P&P) titled, “Hand Hygiene,” revised January 2017, the P&P indicated, “…Purpose…To prevent cross-contamination and home care-acquired infections…Policy…Personnel providing care in the home setting will regularly wash their hands per the most recently published CDC (Centers for Disease Control and Prevention) regulations and guidelines for hand hygiene in healthcare settings…When hands are visibly dirty…they should be washed with either a non-antimicrobial (a substance that kills germs or prevents growth of germs and spread of illness) or antimicrobial soap and water. When hands are not visibly soiled, they should be washed using an alcohol-based hand rub…An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water…Procedure…Hand decontamination with an alcohol-based hand rub…3. Hand decontamination using an alcohol-based hand rub should be performed…A. Before having direct contact with patients…C. After having contact with a patient’s intact skin…E. When moving from a contaminated (containing germs) body site to a clean body site during patient care…F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient…G. After removing gloves…Hand Washing with Soap and Water…6. Hand washing using soap and water should be performed…C. When hands are visibly dirty or contaminated…E. Before and after treating a patient…”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure supervisory visits were completed every 14 days for three of seventeen sampled patients (Patient 3, Patient 6 and Patient 7) receiving Home Health Aide (HHA) services. This failure resulted in a lack of skilled professional oversight and had the potential for the plan of care (POC -a physician ordered, patient-specific document created by a home health agency detailing required medical services, medication, therapies, and equipment to treat an illness or injury at home) to not be followed and for Patient 3, Patient 6 and Patient 7 to not receive their needed care and services. During a review of Patient 7’s clinical document titled, “ PLAN OF CARE,” start of care (SOC) date 5/27/25, the document indicated, “…AID 05-27-25 1-2 x week x 1…[home health aide (HHA) services one to two times per week times one week]…06-01-25 1-2 x week x 8 weeks…” During a concurrent interview and record review on 3/26/26 at 1 PM with the Clinical Director (CD), Patient 7’s clinical visit notes were reviewed. The CD stated when HHA services were provided supervised visits were performed by registered nurses and/or a physical therapist every 14 days. The CD confirmed Patient 7’s HHA services began on 5/27/25 and no supervised visits were documented until 6/20/25. During a review of Patient 6’s clinical document titled, “PLAN OF CARE,” SOC date 2/17/26, the document indicated, “…AID 02-17-26 1 x week x 1…02-22-26 1-2 x week x 8 weeks…” During a concurrent interview and record review on 3/26/26 at 1:05 PM with the CD, Patient 6’s clinical visit notes were reviewed. The CD confirmed Patient 6’s HHA services began on 2/17/26 and no supervised visits were documented for the week of March 1-7, 2026, and there should have been. The CD stated the importance of supervisory visits was to ensure the aids were showing up when they were supposed to and meeting the needs of the patients in their care. The CD stated supervisory visits were required every 14 days to ensure the appropriate care was performed in a professional and competent manner. A review of a facility policy and procedure titled “HOME HEALTH AIDE SUPERVISORY VISITS,” revised11/24, indicated “…To establish guidelines for the responsibilities and the frequency of supervised visits for home health aide personnel…If the patient is receiving skilled services, a registered nurse or other appropriate skilled professional who is familiar with the patient…must complete a supervisory assessment of the aide services being provided no less frequently than every fourteen (14) days…Each supervisory visit shall contain documentation to ensure that the aide is furnishing care in a safe and effective manner…” Findings: During a review of Patient 3’s clinical document titled, “PLAN OF CARE,” start of care (SOC) date 2/21/26, indicated, “…AID 2-22-26 2-3 x week x 9 weeks [home health aide (HHA) services two to three times per week for nine weeks] …” During a concurrent interview and record review on 3/26/26 at 11:57 AM, with the Clinical Director (CD), Patient 3’s clinical visit notes were reviewed. The CD stated when HHA services were provided, supervised visits (on-site evaluations conducted by a Registered Nurse [RN] or therapist to assess the quality of care given by the HHA) were performed by Registered Nurse’s and/or physical therapists every 14 days. The CD confirmed Patient 3’s HHA services during the period of 3/7/26 through 3/21/26 were not supervised. The CD confirmed a supervised visit during this 14-day period was not completed. The CD stated the supervised visits of the HHA were important to make sure the patients were getting their scheduled visits, the HHA’s were following the POC, checking vital signs, and reporting any changes to the licensed nurses.

The following reflects the findings of the California Department of Public Health during a PARTIAL EXTENDED RECERTIFICATION survey conducted on 3/6/23 to 3/21/23. Representing the Department of Public Health: 27390, Health Facilities Evaluator Nurse. Sample Size: Record Review with Home Visits: 7 Record Review without Home Visits: 5 Closed Record Review: 5 Total Sample Size: 17

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to conduct an initial assessment within 48 hours of referral for three of 17 sampled patients (Patients, 1, 4 and 5). This failure resulted in patients not receiving their assessment by the skilled professional in a home setting in a timely manner to develop the necessary plan of care (POC-written document that describes the home health services and items that a patient needs, how often they will receive them, and what outcomes are expected from the treatment). During a review of Patient 1’s “POC”, dated 2/9/23 to 4/9/23, the POC indicated, the start of care (SOC) was 2/9/23. During a review of Patient 1’s “Referral”, dated 2/3/23, the referral indicated, “OK to D/C (discharge) on 2/5/23 with Home Health nursing and PT (physical therapy) /OT (occupational therapy-healthcare profession that focuses on enabling people to do the things they want and need to do in their everyday lives).” During a review of Patient 1’s “Charts/Clinical Note” dated 2/6/23, the note indicated, Patient 1 was discharged from [skilled nursing facility] on 2/5/23 and arrived home on 2/5/23. The initial assessment by registered nurse (RN) was supposed to be conducted by 2/7/23 to meet 48 hours timeframe. The initial assessment was delayed for two days without justification. Patient 1’s primary diagnosis was hypertension and diabetes requiring insulin injection. During a review of Patient 4’s “POC” dated 1/15/23 to 3/15/23, the POC indicated, the SOC was 7/19/22. During a review of Patient 4’s “Referral” dated 7/15/22, the referral indicated, Patient 4’s physician ordered home health to provide skilled nursing and PT. The agency‘s “Packet Scanned to Scheduler” completed by the In-taker indicated, “Date of referral 7/15/22 Date of first visit 7/19/22 Delayed SOC date 7/19/22” The initial assessment by the RN was supposed to be conducted by 7/17/22 to meet 48 hours timeframe. The initial assessment was delayed for two days without justification. Patient 4’s primary diagnosis was metastatic prostate cancer to bone requiring care of indwelling catheter and pain control. During a review of Patient 5’s “POC” dated 2/27/23 to 4/27/23, the POC indicated, the SOC was 2/27/23. During a review of Patient 5’s “Referral” dated 2/23/23, the referral indicated Patient 5’s physician ordered home health to provide PT and Speech Therapy. The initial assessment by PT was supposed to be conducted by 2/25/23 to meet 48 hours timeframe. The initial assessment by PT was delayed for two days without justification. Patient 5’s primary diagnosis was generalized weakness and repeated fall. During an interview on 3/14/23, at 9:15 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated the referral process. The DPCS stated once the intake department receives a referral from the doctor, the Licensed Vocational Nurse (LVN)/Intake Supervisor (IS) reviews referral order, verifies the necessary information and send the referral to Scheduler 1. Scheduler 1 sets the tentative SOC date and assign the new patient to the required discipline to conduct an initial home visit. The RN is assigned to open the case for SN (Skilled Nursing) service ordered. Some cases PT is assigned to open the case, when SN service is not ordered. The discipline assigned to open the case receives notification. The DPCS stated any changes to the scheduled SOC date was required to be documented in the clinical record by the assigned discipline. The DPCS stated she expect the discipline who encounter a delayed SOC date, to notify the doctor and receive the new order. The DPCS stated it was very important to conduct the initial assessment within 48 hours at patient’s home by skilled professional. The delay of the SOC could create negative outcomes, such as worsened wound status, uncontrolled pain, infection, skin breakdown and accidents & falls. The DPCS stated the patient and the home environment needed to be assessed by skilled professional in a timely manner as ordered by the physician to identify the need of DME (durable medical equipment-any medical equipment used in the home to aid in a better quality of living) and education to caregivers. During an interview on 3/15/23, at 10:30 a.m., with the LVN/IS, the LVN/IS stated she was the one who received referrals and completed the packet and scanned the referral information to the scheduler. The LVN/IS stated she determines the SOC depending on the urgency of the service and the availability of the RN and PT. The LVN/IS stated she knew the SOC date need to be within 48 hours from the referral date, but when the delay of SOC occurs, she makes note on the referral, but does not notify physician as required. The LVN/IS acknowledged the delay of SOC date without justification was not an acceptable standard of practice. During an interview on 3/16/23, at 1:30 p.m., with Scheduler 1, Scheduler 1 stated when she received referrals from the LVN/IS the SOC date is already determined. Scheduler 1 stated her job is to schedule the home visit on the date determined by the LVN/IS to the appropriate discipline. During an interview with on 3/16/23, at 2 p.m., with the Administrator (Adm), the Adm stated LVN/IS needed to schedule the SOC date within 48 hours from the referral for the skilled professional to open the case. The Adm stated the current practice of allowing the LVN/IS to pick and choose the SOC date created unjustified delay of the SOC. The Adm realized by the time the referral was given to the scheduler, the SOC date was already delayed. The Adm also identified the lack of clinical documentation identifying the reason(s) for a delayed SOC and evidence of obtaining a new SOC order from the physician. The Adm stated she would in-service the LVN/IS to write the SOC within 48 hours from the referral date, so the scheduler could assign the necessary discipline to make home visit within 48 hours from the referral date. During a review of the agency’s policy and procedure (P&P) titled, “Initial and Comprehensive Assessment” dated 4/21, the P&P indicated, “An initial assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician (or other authorized licensed independent practitioner, or at the patient/family request with the approval of the physician (or another authorized licensed independent practitioner).”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to administer occupational therapy (OT) as ordered by the physician for five of 17 sampled patients (Patients, 1, 2, 3, 6 and 11) when the OT service was discontinued without physician’s order. This failure resulted in patients not receiving their assessment by OT as ordered by the physician expected to develop the plan of care (POC-written document that describes the home health services and items that a patient needs, how often they will receive them, and what outcomes are expected from the treatment). During an entrance conference interview on 3/6/23, at 1:30 p.m., with the Clinical Supervisor (CS), the CS stated the OT was on a leave for two weeks. The CS stated currently the agency did not have patients who needed OT service. During an interview on 3/6/23, at 2:50 p.m., with the Administrator (Adm), the Adm stated the current employed OT was out for a month from 3/1/23 to 4/1/23. The Adm stated it was a planned leave of absence and the OT discharged patients from OT service prior to his absence. The Adm stated the staff were instructed not to accept any new referral needing OT during OT’s absence. The Adm stated when any of the existing patients needing OT services, the agency would have referred to outside contracted OT for immediate needs. During a review of Patient 1’s “Referral”, dated 2/3/23, the referral indicated, “OK to D/C (discharge) on 2/5/23 with Home Health nursing and PT (physical therapy) /OT (occupational therapy-healthcare profession that focuses on enabling people to do the things they want and need to do in their everyday lives).” Patient 1’s clinical record was reviewed to validate the OT service had been provided as the referral indicated. Patient 1’s POC dated 2/9/23 to 4/9/23, did not contain an OT evaluation. Patient1’s “Charts/Clinical Note” did not contain a physician order to discontinue the OT evaluation. During a review of Patient 2’s “Physician Order”, dated 10/3/22, the physician order indicated, “HH (home health) OT to start skilled services effective 09/30/22 1W1 (once a week); 1W1 (once a week); 1-2W2 (once or twice a week for 2 weeks) for OT evaluation., ADL (activities daily living) re-training, therapeutic activities/exercises and PCG (patient care giver) education on safety and HEP (Home Exercise Program).” Patient 2’s clinical record was reviewed to validate the OT service had been provided as physician ordered. Patient 2’s “Charts/Clinical Note” dated 10/19/22, the clinical note indicated, “Patient to be discharged from HH OT at this time.” No follow up visit was made after the evaluation due date. to patient’s wife’s request. MD notified.” Patient 2’s clinical record did not contain OT’s attempts to contact order to receive DC order. OT discontinued the service then notified the physician. During a review of Patient 3’s “Referral”, dated 2/14/23, the referral indicated, “Resident discharging her home on Friday Feb 17, 2023 at 8:30 AM, family will be picking up for transport with all remaining medications. Home health, PT/OT evaluation and nursing? [sic].” Patient 3’s “POC” dated 2/18/23 to 4/18/23, did not contain an OT evaluation. Patient 3’s “Charts/Clinical Note” did not contain physician order to discontinue the OT evaluation. During a review of Patient 6’s “Physician Order”, dated 2/21/23, the order indicated, “Home Health/Supportive Care (OT/PT and speech therapy eval [evaluation] and tx [treatment.]” Patient 6’s “Clinical Record” was reviewed to validate the OT service had been provided as the referral indicated. Patient 6’s “POC” dated 2/1/23 to 4/1/23, did not contain OT evaluation. Patient 6’s “Charts/Clinical Note” did not contain physician order to discontinue the OT evaluation. During a review of Patient 11’s “Referral”, dated 2/15/23, the referral indicated, “Home Health SN (skilled nursing), PT & OT.” Patient 11’s “Clinical Record” was reviewed to validate the OT service had been provided as the referral indicated. Patient 11’s “POC” dated 2/16/23 to 4/16/23, did not contain OT evaluation. Patient 11’s “Charts/Clinical Note” did not contain physician order to discontinue the OT evaluation. During an interview on 3/14/23, at 9:15 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated the referral process. The DPCS stated once the intake department receives a referral from the doctor, the Licensed Vocational Nurse (LVN)/Intake Supervisor (IS) reviews referral order, verifies the necessary information and send the referral to Scheduler 1. Scheduler 1 sets the tentative SOC date and assign the new patient to the required discipline to conduct an initial home visit. The RN is assigned to open the case for SN (Skilled Nursing) service ordered. Some cases PT is assigned to open the case when SN is not ordered. The DPCS stated she oversaw RNs, and the Physical Therapy Supervisor (PTS) oversaw therapy department including OT. During an interview on 3/15/23, at 10:30 a.m., with the LVN/IS, the LVN/IS stated she was the one who receives referral and completes the packet and scans the referral information to the scheduler. The LVN/IS stated the OT was on a leave from middle of January and the agency expected him to return to work on 3/19/23. The LVN/IS validated she omitted OT service on the referral without obtaining physician’s order to discontinue OT service during the OT leave. The LVN/IS stated she did not have any documented evidence that she communicate with the Adm, CS or PTS prior to accepting referrals with OT services ordered. The LVN/IS admitted the scheduler or the case managers would not know OT services were ordered on the initial referral since the scheduler and the Adm did not observe the OT on the referral prior to the LVN/IS scanned orders to the scheduler. During a telephone interview on 3/16/23, at 9:41 a.m., with the Physical Therapy Supervisor (PTS), the PTS stated she was aware OT would not be available for a month. The PTS stated, as a supervisor, it was her responsibility to ensure the patients with OT service needs were met. The PTS stated if she knew there was a new referral for OT during the absence of the OT, she could have decided whether to accept the patient or not, and if accepted she could have provided OT evaluation. The STS stated it was not an acceptable standard of practice to be omitting OT order without physician’s order to discontinue the service. During an interview on 3/16/23, at 1:30 p.m. with Scheduler 1, Scheduler 1 stated when she receives a referral from the LVN/IS the SOC date and service ordered are already determined. Scheduler 1 stated her job is to schedule the home visit on the date determined by the LVN/IS to the appropriate discipline. During an interview on 3/16/23, at 2 p.m., with the Adm, the Adm stated there was a lack of communication and supervision of the therapy department. The Adm stated the current practice of allowing LVN/IS to omit OT order during absence of OT service was not an acceptable standard of practice. The Adm stated LVN/IS should have contacted the physician and documented the new order prior to accepting the patient. The Adm realized by time the referral comes to the scheduler, the OT service ordered were not included, therefore the scheduler or the case managers would not know OT services was ordered. The Adm stated she would in-service the LVN/IS to consult with her on any dilemma with PTS to administer a physician’s OT order. During a telephone interview on 3/20/23, at 4:31 p.m., with the OT, the OT stated he took scheduled time off from 2/9/23 to 3/16/23. The OT stated he informed the PTS about his approved leave of absence. The OT stated when he left, he discharged two patients who did not need the service any longer. The OT stated when the service was no longer needed or patient cancelled/refused service, he notified the scheduler and did not contact the physician to receive a DC order. During a review of the agency’s policy and procedure (P&P) titled, “Physician Participation in Plan of Care” dated 4/21, the P&P indicated, “The care will be provided in compliance with therapeutic and diagnostic orders and accepted standards of practice. The clinical record will be made available to the physician(s) (or other authorized licensed independent practitioner) issuing orders for the plan of care and appropriate personnel…When services are provided on the basis of physician’s verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date and time the orders…Orders are reviewed for appropriateness and accuracy before care, treatment and services are provided. The organization may assist the physician (or other authorized licensed independent practitioner) in determining medical necessity and formulating an appropriate plan of care, if requested by the physician (or other authorized licensed independent practitioner).”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to coordinate patient’s need for durable medical supply (items that are disposable to help with certain medical conditions or illness) for one of seven sampled patients with home visits (Patient 6) when Patient 6’s caregiver was provided inappropriate gauze supply for Patient 6’s gastrostomy (an opening into the stomach from the abdominal wall made surgically for the introduction of food) care. This failure had the potential for Patient 6 to develop skin irritation and infection around the gastrostomy, caused by extended use of inappropriate gauze. During a concurrent observation and interview on 3/9/23, at 11 a.m., with Patient 6’s caregiver, in Patient 6’s home, Patient 6’s caregiver presented an unopen gauze package. The package contained a sterile woven gauze sponges 4X4 inches. The caregiver stated the gauze he received recently was not the appropriate type and was different from what he had received in the past. The caregiver stated the gauze was thin, coarse and would not contain liquid when in contact to the gauze. Patient 6’s caregiver demonstrated how thin the gauze was and pointed that gauze was permeable (allowing liquids or gases to pass through it) resulting in Patient 6’s skin being in contact with liquids and not absorbed by the provided gauze. Patient 6’s caregiver stated he told Licensed Vocational Nurse (LVN) 1 about the problem and she agreed that the gauze provided to him was not the correct one to use and instructed him to use a zip-lock to contain the leakage. During a review of Patient 6’s “Plan of Care (POC-written document that describes the home health services and items that patient needs, how often they will receive them, and what outcomes are expected from the treatment) dated 2/2/23 to 4/1/23, the POC indicated, “G (gastrostomy) -tube cleans with ([Brand name for sodium hypochlorite]-antiseptic solution) and apply drain gauze daily” During an interview on 3/14/23, at 10:50 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated LVN 1 made a home visit to Patient 6 on 2/28/23. The DPCS stated LVN 1’s visit note did not reflect any reported issues or instruction she provided to Patient 6’s caregiver. During an interview on 3/16/23, at 8:40 a.m., with LVN 1, LVN 1 stated she recalled Patient 6’s caregiver demonstrating the extreme thinness of the gauze and leaking because the gauze did not contain liquid to her during a home visit. LVN 1 stated she instructed him to use a zip-lock to protect against the leakage. LVN 1 stated she told Patient 6’s caregiver that it was not the right type of gauze to take care of G tube, but she hoped the next shipment would have the right type of gauze. LVN 1 stated she did not make any further step to resolve the issue. LVN 1 stated she did not think it was an important issue to report to her supervisor, Registered Nurse (RN) 1. LVN 1 stated she assumed the bad batch of gauze Patient 6 received would be used up and hopefully the appropriate batch of gauze would arrive next shipment. LVN 1 stated she understood the purpose of Patient 6’s skilled nursing service was to ensure the drainage around the G tube would be absorbed efficiently to prevent skin irritation and infection. During an interview on 3/16/23, at 2 p.m., with the Administrator (Adm), the Adm stated the type of gauze Patient 6 received was not the agency’s durable medical supply formulary for G tube care. The Adm stated the agency’s formulary for G-tube care was “Non-Woven Gauze Sponges 4X4 IN (inches) 4-Ply Low linting Extra absorbent.” The Adm stated LVN 1 should have elevated the supply concern to a higher level to resolve the problem. The Adm stated LVN 1 should have communicated with RN 1, the Adm, DPCS or Clinical Supervisor when she encountered any concerns during her home visit. During a telephone interview on 3/20/23, at 2:11 p.m., RN 1 stated Patient 6’s caregiver had been using weaved gauze which was used for peeling not for covering G-tube area for absorb drainage. RN 1 stated the supply order got mixed up and he expected LVN 1 to notify him as soon as she identified the wrong supply had been sent out. RN 1 stated he would talk to LVN 1 on the importance of receiving the correct supply to follow the POC. RN 1 stated it was very important for LVN 1 to communicate any concerns the caregiver might have had during her home visit to coordinate care to achieve the POC. During a review of the agency’s policy and procedure (P&P) titled, “Care/Service Coordination” dated 8/20, the P&P indicated, “Care coordination will include, but not be limited to: Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in the coordination of care activities.”