Every finding on record at Cp Orange County South S-Ca Hh LLC

AMENDED The following reflects the findings of the California Department of Public Health during the complaint investigation for Complaint Number 2980510. The survey team entered the HHA on 5/6/26 at 0815 hours. Inspection was limited to the authorized Conditions of Participation (CoPs) reviewed and did not represent the findings of a full inspection of the agency. The HHA identified the census as 681. GLOSSARY AND DEFINITIONS: CHHA: Certified Home Health Aide DCS: Director of Clinical Services ED: Executive Director HH: Home Health HHA: Home Health Agency mg: milligram(s) ml: milliliter(s) MSW: Medical Social Worker P&P: Policy and Procedure POC: Plan of Care RN: Registered Nurse SOC: Start of Care WK: week

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included the patient’s current medications to identify any potential adverse effects and drug reaction for one of three sampled patients (Patient 3). This failure had the potential risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for this patient. Review of the agency’s P&P titled Initial and Comprehensive Assessments Recertification Assessment and Timing revised 2/27/26, showed the purpose of the procedure was to provide specific guidance to the members of the home health interdisciplinary team licensed professionals regarding the performance of the initial home health assessment and ongoing comprehensive assessments to ensure information is collected, documented, and presented to the patient’s provider in a timely and consistent manner. Procedures showed medication inventory to include medications the patient is actively prescribed, medications the patient has on hand, over-the-counter medications, and herbal preparations as well as any substances the patient use recreationally or for permitted medical use. Medication inventory provides the basis for medication reconciliation and appropriate medication management to support patient goals for care, and medication inventory ensures medications which are high risk or high-alert are recognized and address quickly by the home health clinical team members. Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification periods from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The Client Medication Report for the certification period 4/26/26 to 6/24/26, showed the patient’s medications included the following: -Basaglar KwikPen insulin (used to manage blood sugar levels) 100 unit/ml (3 ml) subcutaneous inject 10 ml at bedtime for diabetes. -Dermal Wound Cleanser as ordered prior to applying unna boot (used to treat venous insufficiency). -Ozempic (used to improve blood sugar control) 0.25 mg or 0.5 mg (2 mg/3 ml) subcutaneous pen injector 0.5 mg weekly for diabetes. However, the medications at the patient’s home showed the following: -Basaglar KwikPen insulin 100 unit/ml (3 ml) subcutaneous inject 35 units in the morning for diabetes. -Ozempic 0.25 mg or 0.5 mg (2 mg/3 ml) subcutaneous pen injector 0.25 mg every Sunday for diabetes. Both medications' dosage were not consistent with the Client Medication Report. In addition, The Home Health Certification and Plan of Care for the certification period from 4/26/26 to 6/24/26, did not include an order for the application of the unna boot and the following medications that the patient was on: -loperamide (antidiarrheal) 2 mg one tablet as needed. -Centrum 50 + (supplement) one tablet daily. -triple action joint health (supplement) one pill a day. -Benefiber probiotic (fiber supplement) one gummy daily. A joint home visit with RN 1 and DCS 2 was conducted on 5/7/26 at 1200 hours, to Patient 3’s home. RN 1 confirmed the medication profiles were not updated. DCS 2 was observing and acknowledged the findings. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified the findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was notified of the missed visit for one of three sampled patients (Patient 1). This failure had the potential for not addressing the care needs for this patient. Review of the agency’s P&P titled Written and Verbal Orders revised 1/31/24, showed if a physician order cannot be carried out, the professional who identifies the issue notifies the physician of the concern and obtains new orders to clarify the delivery of care, for example: missed visits (patient declines a visit and declines to reschedule, patient is hospitalized, etc.) Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. Review of the Home Health Certification and Plan of Care for certification period from 1/29/26 to 3/29/26, showed MSW visits 1WK1 (one visit a week for one week), effective 2/1/26. However, there was no documented evidence of the MSW visit during the week of 2/1/26 - 2/7/26. DCS 2 was asked and stated the MSW had a missed visit on 2/6/26, and it was rescheduled. However, DCS 2 was unable to provide documentation why the visit was missed and if the physician was notified of the missed rescheduled visit. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review was conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient received care and services as per the written POCs for one of three sampled patients (Patient 3). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification period from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The POC, for the certification period 2/25/26 to 4/25/26, showed SN visits 1WK9 for skilled nurse to evaluate and develop the plan of care to be countersigned by the physician. Review of the Visit Note Report dated 4/2/26, showed wound care to the right lower leg was performed and collagen dressing was applied with a four-by-four gauze covering for nighttime protection. However, the POC, for the certification period 2/25/26 to 4/25/26, did not include an order for the application of collagen dressing with four-by-four gauze covering the patient’s right lower leg for nighttime protection. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the coordination with the physician regarding obtaining the patient’s weight for one of three sampled patients (Patient 3). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification period from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The POC for certification period 4/26/26 to 6/24/26, showed SN visit 1WK9. The POC included for the SN to notify physician if patient gains more than three pounds for 24 hours or five pounds in a week. However, there was no documented evidence of coordination with the physician to clarify who was responsible for obtaining the patient’s weight. Review of the Visit Note Report dated 4/30/26, showed no documented evidence of the patient’s weight. Moreover, during a joint home visit with RN 1 and DCS 2 conducted on 5/7/26 at 1200 hours, to Patient 3’s home, RN 1 confirmed the patient’s weight was not obtained during the visit. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1, and DCS 2. DCS 2 acknowledged and verified the findings. Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification period from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The POC for certification period 4/26/26 to 6/24/26, showed SN visit 1WK9. The POC included for the SN to notify the physician if the patient gains more than three pounds for 24 hours or five pounds in a week. However, there was no documented evidence of coordination with the physician to clarify who was responsible for obtaining the patient’s weight and how often to weight the patient. Review of the Visit Note Report dated 4/30/26, showed no documented evidence of the patient’s weight. Moreover, during a joint home visit with RN 1 and DCS 2 conducted on 5/7/26 at 1200 hours, to Patient 3’s home, RN 1 confirmed the patient’s weight was not obtained during the visit. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for two of three sampled patients (Patients 1 and 2). This failure created the increased risk of substandard healthcare outcomes for these patients as their clinical information was not accurate. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. The Client Medication Report for the certification period 1/29/26 to 3/29/26, showed the patient’s medications included the following: -simvastatin (lipid lowering medication) 20 mg taken daily for cholesterol. -tamsulosin (medication used to treat enlarged prostate) 0.4 mg two times daily for prostate. -trazodone (antidepressant) 100 mg daily for insomnia. Review of the Visit Note Reports showed Patient 1 was assessed for pain. For example, the Visit Note Reports dated on the following dates indicated pain was managed by medications, rest, position changes and distraction: -On 2/3/26, 2/10 (0=no pain, 1-3=mild pain and 10=worst pain) left knee pain. -On 2/5/26, 1/10 left knee pain. -On 2/13/26, right hip pain. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0940 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1, and DCS 2. The HH Director of Quality Outcomes acknowledged and verified the findings. 2. Review of Patient 2’s clinical record was initiated on 5/6/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification period from 1/16/26 to 3/16/26 and 3/17/26 to 5/15/26. The Client Medication Report for the certification period 3/17/26 to 5/15/26, showed the patient’s medications included the following: -bupropion HcL (antidepressant) 100 mg one tablet twice daily. -Eliquis (blood thinner) 5 mg one tablet twice daily. -metoprolol tartrate (antihypertensive medication) 25 mg one half tablet twice daily. Review of the Visit Note Reports showed Patient 2 was assessed for pain. For example, the Visit Note Reports dated 4/1 and 4/30/26 showed the patient’s pain was managed by medications, rest, position changes, and distraction. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and DCS 2. The HH Director of Quality Outcomes acknowledged and verified the findings. 1. Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. The Client Medication Report for the certification period 1/29/26 to 3/29/26, showed the patient’s medications included the following: -simvastatin (lipid lowering medication) 20 mg taken daily for cholesterol. -tamsulosin (medication used to treat enlarged prostate) 0.4 mg two times daily for prostate. -trazodone (antidepressant) 100 mg daily for insomnia. Review of the Visit Note Reports showed Patient 1 was assessed for pain as follows: -On 2/3/26, 2/10 (0=no pain, 1-3=mild pain and 10=worst pain) left knee pain. -On 2/5/26, 1/10 left knee pain. -On 2/13/26, right hip pain. The documents showed the pain was managed by medications, rest, position changes and distraction. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0940 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS and 2. The HH Director of Quality Outcomes acknowledged and verified the findings. 2. Review of Patient 2’s clinical record was initiated on 5/6/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification period from 1/16/26 to 3/16/26 and 3/17/26 to 5/15/26. The Client Medication Report for the certification period 3/17/26 to 5/15/26, showed the patient’s medications included the following: -bupropion HcL (antidepressant) 100 mg one tablet twice daily. -Eliquis (blood thinner) 5 mg one tablet twice daily. -metoprolol tartrate (antihypertensive medication) 25 mg one-half tablet twice daily. Review of the Visit Note Reports showed Patient 2 was assessed for pain. For example, the Visit Note Reports dated 4/1 and 4/30/26, showed the patient’s pain was managed by medications, rest, position changes, and distraction. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. The HH Director of Quality Outcomes acknowledged and verified the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency's RN or other appropriately skilled professional provided the onsite supervision for the HHA no less frequently than every 14 days to ensure quality of care and services provided for one of three sampled patients (Patient 1). This failure had the potential for substandard health outcomes to this patient. Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. Review of the Home Health Certification and Plan of Care for the certification period from 1/29/26 to 3/29/26, showed CHHA visits 1WK1, 2WK2, and 1WK1, effective 2/1/26. The HHA notes showed the CHHA visits were conducted during Week 2 (2/1/26 to 2/7/26), Week 3 (2/8/26 to 2/14/26, Week 4 (2/15/26 to 2/21/26), and Week 5 (2/22/26 to 2/28/26). Review of the physician’s order dated 3/4/26, showed a request for CHHA once weekly for four weeks, effective 3/1/26. The CHHA notes showed the CHHA visits were conducted during Week 6 (3/1/26 to 3/7/26) and Week 7 (3/8/26 to 3/11/26). However, there was no documented evidence the RN or other appropriately skilled professional completed a supervisory visit for the CHHA no less frequently than every 14 days from 2/1/26 to 3/11 26. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. The Director of Quality Outcomes verified the findings.

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN; 39539, HFEN; and 39210, HFEN. The survey team entered the Home Health Agency on 7/6/23 at 1245 hours. The survey team reviewed thirteen active and five closed clinical records. The agency was in substantial compliance with the requirements for Emergency Preparedness.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN; 39539, HFEN; and 39210, HFEN. The survey team entered the Home Health Agency on 7/6/23 at 1245 hours. The survey team reviewed thirteen active and five closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: BID: twice a day BM: bowel movement bpm: beats per minute CDC: Centers for Disease Control and Prevention C-diff: Clostridium difficile (a contagious bacterium that causes symptoms ranging from diarrhea to life threatening inflammation of the colon) CHHA: Certified Home Health Aide cm: centimeter(s) coccyx: tail bone COVID 19: an infectious disease caused by the SARS-CoV-2 virus DPCS: Director of Patient Care Services g: gram(s) GACH: General Acute Care Hospital GERD: Gastroesophageal Reflux Disease (digestive disorder that affects the ring of muscle between your esophagus and your stomach) GI: Gastrointestinal GT: Gastrostomy tube (a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) Hepatitis B: a serious liver infection caused by the hepatitis B virus HHA: Home Health Agency Indwelling catheter: (a catheter inserted through the urethra into the bladder to drain urine) IV: Intravenous IVPB: intravenous piggyback (method of medication administration commonly used for medical treatments, especially antibiotics) Jackson-Pratt surgical drain: closed suction device, meaning that the fluids are collected within a closed system, without the need for an outside suction machine LVN: Licensed Vocational Nurse MD: Medical Director mg: milligram(s) mmHg: millimeters of mercury ml: milliliter(s) NS: normal saline OASIS: Outcome and Assessment Information Set OT: Occupational Therapy/Therapist P&P: policy and procedure PCG: Patient Care Giver PICC: Peripherally inserted central catheter (is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near the heart) pneumonia: infection that affects one or both lungs. PO: by mouth POC: Plan of Care port-a-cath: implanted port (device placed under the skin and used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs. It is also used for taking blood samples). PRN: as needed PT: Physical Therapy/Therapist Q: Every QA: Quality Assurance QAPI: Quality Assurance and Performance Improvement QD: Every day QID: four times a day QM: Quality Management RN: Registered Nurse ROC: Resumption of Care sacrum: shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis SBP: systolic blood pressure SC: subcutaneous SN: Skilled Nurse SNF: Skilled Nursing Facility SOC: Start of Care Stage 2 pressure injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. TB: tuberculosis (disease caused by germs that are spread from person to person through the air) Tetanus: an infection caused by bacteria called Clostridium tetani TID: three times a day u: unit(s) UTI: Urinary Tract Infection W: week

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed accurately and consistent with the patients’ immediate care needs for ten of 18 sampled patients (Patients 2, 4, 6, 8, 9, 10, 12, 14, 17, and 18). These failures created the risk of not identifying and addressing the care needs for these patients. #. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. The SOC OASIS dated 5/14/23, showed wound care for surgical wound on right foot performed as ordered by SN. However, there was no documented evidence of the measurement of the patient’s surgical wound on the right foot. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The SOC OASIS dated 2/10/20, showed a section under the most recent immunization to fill out with a yes, no, and unknown answer on the patient’s tetanus, TB, TB exposure, and hepatitis B. However, the section was blank. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 10's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 5/26/23. The patient was certified for home health services during the certification period from 5/26/23 to 7/24/23. The faxed document from the SNF dated 5/23/23, showed a physician’s order to discharge home on 5/24/34. Documentation showed home health PT/OT for safety evaluation and treatment if indicated, home health RN for medication and oxygen management, and bath aide for help with bathing. The SOC OASIS dated 5/26/23, showed disciplines ordered and indicated were PT, OT, and SN. However, there was no documented evidence of an information/explanation for not including CHHA as per the faxed document from the SNF dated 5/23/23. On 7/20/23 at 0946 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 12's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 1/27/23. The patient was certified for home health services during the certification period from 5/27/23 to 7/25/23. The SOC OASIS 1/27/2023, showed the RN conducted the visit. However, there was no documented evidence the patient’s cardiovascular status was assessed. On 7/20/23 at 1049 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 14's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 3/6/22. The patient was certified for home health services during the certification periods from 3/6/22 to 5/14/22 and 5/15/2022 to 7/3/2022. The SOC OASIS dated 3/6/2022, showed the nutritional requirement was enteral diet. Documentation showed the patient was instructed in site care, change of appliance, stoma care, enteral feeding schedule, signs and symptoms of infection and to notify RN/physician. The patient and/or caregiver verbalized understanding. Documentation showed the primary reason nursing was ordered was G-tube management and instruction to patient on how to use and care. Documentation showed under the open wound care problem, the patient had a right foot open wound. However, there was no documented evidence on the status/assessment of the G-tube site. There was no documented evidence on what the measurement of the right foot open wound was. On 7/20/23 at 1158 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 18’s clinical record was initiated on 7/17/23. The clinical record showed the SOC was 1/21/23. The patient was certified for home health services during the certification period from 5/21/23 to 7/19/23. The SOC OASIS dated 1/21/23, showed no documented evidence the assessment for the patient’s capillary refill was completed. Documentation showed the patient had a scalp wound laceration. However, there was no documented evidence of the measurement of the wound. On 7/20/23 at 1103 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the finding. #. Review of Patient 15's closed clinical record was initiated on 7/12/23. The clinical record showed the SOC was 2/23/22. The patient was certified for home health services during the certification period from 2/23/22 to 4/23/33. The SOC OASIS dated 2/23/22, showed the patient had a skin tear on the left lower arm with a measurement of 6 cm (length) x 0.5 cm (width). The patient also had a right medial buttock denuded moisture damage wound with a measurement of 1 cm (length) x 1.5 cm (width). However, there was no documented evidence of the wound depth on the left lower arm skin tear and right medial buttock denuded moisture damage wound. On 7/20/23 at 1149 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. Review of the agency's P&P titled Initial and Comprehensive Assessment dated 7/2023, showed the assessment will be patient-specific and comprehensive to include the patient's need for home health care, rehabilitative care, social services, and discharge planning. The assessment will also include the exact use of the current versions of the Outcomes and Assessment Information Set (OASIS). 1. Review of Patient 2's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 11/4/22. The patient was certified for home health services during the certification periods from 5/3/23 to 7/1/23 and 7/2/23 to 8/30/23. Review of the SOC OASIS dated 11/4/22, showed no documented evidence the patient’s height and weight were assessed. On 7/20/23 at 0858 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification periods from 4/25/23 to 6/23/23 and 6/24/23 to 8/22/23. Review of the SOC OASIS dated 4/25/22, showed no documented evidence the patient’s height and weight were assessed. On 7/20/23 at 0920 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 3. Review of Patient 8's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 12/30/22. The patient was certified for home health services during the certification periods from 4/29/23 to 6/27/23 and 6/28/23 to 8/26/23. Review of the SOC OASIS dated 12/30/22, showed no documented evidence the patient’s respiratory pattern and effort were assessed. On 7/20/23 at 1015 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were updated to reflect the patients' current medications and included the specific indications and parameters for their use for eight of 18 sampled patients (Patients 2, 3, 4, 5, 6, 12, 16, and 18). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. #. Review of Patient 3's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 6/8/23. The patient was certified for home health services during the certification period from 6/8/23 to 8/6/23. The medication profile, for the certification period from 6/8/23 to 8/6/23, showed the patient’s medications included Tylenol (analgesic) 325 mg two tablets PO Q four hours PRN for pain, Invanz (antibiotic) 1 g inject 1 g over 30 minutes Q 24 hours, heparin (anticoagulant) lock flush inject 5 ml into the vein daily, and normal saline inject 10 ml into the vein two times daily. A joint home visit with RN 2 was conducted on 7/10/23 at 0800 hours, to Patient 3's home. Review of the patient's medications was conducted with the patient. Patient 3 stated she was taking Olly Probiotic (supplement) two gummies a day. She stated she took the probiotics since June when the IV antibiotic was started. However, there was no documented evidence the probiotics was included in the patient’s medication profile. In addition, there was no documented evidence on what the concentration of the heparin lock flush was. On 7/10/23 at 849 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the finding. #. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. The medication profile, for the certification period from 5/14/23 to 7/12/23, showed the patient’s medications included aspirin (nonsteroidal anti-inflammatory drug) 81 mg chewable tablet chew and swallow one tablet daily; atorvastatin (lipid-lowering drug) 10 mg take four tablets by mouth nightly; carvedilol (antihypertensive) 3.125 mg one tablet by mouth BID; clopidogrel (antiplatelet) 75 mg one tablet by mouth daily; empagliflozin (antidiabetic) 10 mg one tablet by mouth daily; fish oil (supplement) 1,000 mg one capsule by mouth TID; glimepiride (blood-glucose-lowering drug) 4 mg one tablet by mouth every morning before breakfast; and metformin (anti-hyperglycemic agent) 1,000 mg one tablet by mouth BID with breakfast and dinner. A joint home visit with LVN 2 was conducted on 7/10/23 at 1030 hours, to Patient 6's home. Review of the patient's medications was conducted with the patient and LVN 2. The patient stated he was taking pantoprazole sodium (used for GERD) 40 mg QD for six months. However, there was no documented evidence pantoprazole was in the medication profile. LVN 2 was informed of the finding. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the finding. #. Review of Patient 12's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 1/27/23. The patient was certified for home health services during the certification period from 5/27/23 to 7/25/23. The medication profile for the certification period from 5/27/23 to 7/25/23, showed the patient’s pain medication included acetaminophen (analgesic) 650 mg PO BID PRN for fever/pain; lidocaine hcl (local anesthetic agent) 2% five ml plus bupivacaine PF (local anesthetic) 0.75% five ml solution, take five ml PO every three hours PRN for mouth pain; and tramadol (opioid analgesic) 50 mg PO Q six hours PRN for pain. * However, there was no documented evidence of specific information on when to administer acetaminophen and tramadol for pain. On 7/20/23 at 1049 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the finding. #. Review of Patient 18’s clinical record was initiated on 7/17/23. The clinical record showed the SOC was 1/21/23. The patient was certified for home health services during the certification period from 5/21/23 to 7/19/23. The medication profile for the certification period from 5/21/23 to 7/19/23, showed the patient’s medication included hydrocodone-acetaminophen (opioid analgesic) 10-325 mg per tablet take one to two tablets PO Q four hours PRN for pain. * However, there was no documented evidence of specific information on when to administer one or two tablets of hydrocodone-acetaminophen. On 7/20/23 at 1103 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the finding. X. Review of Patient 2's clinical record was initiated on 7/7/23. The clinical record showed the SOC was 11/4/22. The patient was certified for home health services during the period from 5/3/23 to 7/1/23 and 7/2/23 to 8/30/23. The medication profile, for the certification period from 7/2/23 to 8/30/23, included the following medications: acetaminophen 500mg two tablets PO three times daily as needed for pain; atorvastatin 20mg one tablet daily in the evening; clopidogrel 75mg one tablet daily; docusate sodium 100mg one to two tablets PO daily; fluconazole 100mg (an antifungal medication) PO daily; gabapentin 400mg, one capsule PO three times daily; hydrochlorothiazide 12.5 mg one capsule PO daily; Hydrocodone- acetaminophen 5- 325 mg (a medication used for pain) one tablet PO every six hours for pain; insulin glargine 100 units/ ml (a medication used for diabetes) 10 units under the skin nightly; metformin 1,000 mg, one tablet PO two times daily; naloxone 4mg/ nasal spray one spray dose into 1 nostril prn emergency use in case of opioid overdose and unconscious to revive; neomycin- bacitracin- polymyxin apply three times a week to right foot wound during wound care; polyethylene glycol, one diluted packet by mouth two times daily as needed; tramadol two tablets my mouth four times daily as needed for pain; and valsartan 40mg one tablet by mouth daily. A joint home visit with RN 1 was conducted on 7/7/23 at 1107 hours, to Patient 2's home. Review of the patient's medications was conducted with Patient 2 and RN 1 showed Patient 2 was no longer taking fluconazole. Further review of the patient's medications showed Patient 2 was taking zinc and vitamin supplements for the past two months. On 7/20/23 at 1140 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed of the findings. Review of the agency's P&P titled Medication Profile dated 8/2020 showed patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. 1. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification period from 6/24/23 to 8/22/23. On 7/10/23 at 0943 hours, a joint home visit was conducted with PT 1 to Patient 4’s home. Review of the patient’s medications with PT 1 showed the patient was taking Lasix (diuretic) 20 mg PO QD instead of 40 mg, Diovan (antihypertensive) 80 mg PO QD instead of Q 12 hours, and Percocet (narcotic) 5/325 mg one tablet PO QD, one hour prior to PT twice a week, instead of two tablets Q four hours PRN for pain. On 7/10/23 at 1028 hours, an interview and concurrent clinical record review was conducted with PT 1. PT 1 was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 7/11/23. The clinical record showed the SOC was 6/30/23. The patient was certified for home health services during the certification period from 6/30/23 to 8/28/23. On 7/11/23 at 0800 hours, a joint home visit was conducted with CHHA 1 to Patient 5’s home. Review of the patient’s medications with the PCG and CHHA 1 showed the patient was taking gabapentin (anticonvulsant and nerve pain medication) 300 mg PO TID instead of QID. In addition, the PCG verified the patient was also not taking the lidocaine (anesthetic) and methocarbamol (muscle relaxant). However, these medications were still listed in the patient’s medication profile. On 7/20/23 at 0954 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed of the finding. 3. Review of Patient 16's closed clinical record was initiated on 7/17/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification period from 12/22/22 to 2/19/23. The Medication Profile for the certification period from 12/22/22 to 2/19/23, showed the patient’s medications included Atarax (antihistamine) 10 mg one to two tablets nightly PRN. However, there was no documented evidence in the medication profile showing the specific indication for the PRN medication and when to take one versus two tablets. On 7/20/23 at 1100 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the updated comprehensive assessments were completed accurately and consistent with the patients’ immediate needs for three of 18 sampled patients (Patients 2, 8, and 9). These failures created the risk of not identifying and addressing the care needs for these patients. #. Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The Recert OASIS dated 3/4/23, showed the patient had a right foot diabetic ulcer. Documentation showed the measurement was 1.5 cm (length) X 0.3 cm (width) However, there was no documented evidence of the depth of the patient’s right foot diabetic ulcer. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 1. Review of Patient 2's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 11/4/22. The patient was certified for home health services during the certification period from 5/3/23 to 7/1/23. The POC, for the certification period from 5/3/23 to 7/1/23, showed to clean and dress the patient’s right hallux (big toe) wound three times per week and as needed. The POC showed to measure the wound weekly. Review of the SN Recert OASIS dated 6/28/23, showed no documented evidence of the patient’s wound assessment and measurements. On 7/20/23 at 0858 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 2. Review of Patient 8's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 12/30/22. The patient was certified for home health services during the certification period from 4/29/23 to 6/27/23. Review of the Recert OASIS dated 4/24/23, showed the patient’s nutritional requirements included diabetic diet and GT feeding. However, the type and amount of feeding the patient required were not documented. On 7/20/23 at 1015 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the update comprehensive assessment were completed within 48 hours of the patient's return to home from the hospital for two of 18 sampled patients (Patients 6 and 14), creating the risk of not providing the necessary care and services timely to meet the care needs for these patients. Findings: 1. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. a. The ROC OASIS dated 6/11/23, showed the patient had one observable surgical wound. Documentation showed the patient resumed home health care following a hospitalization for possible heart surgery. Documentation showed the patient presented with mobility issues, unsteady gait due to open wound of foot and wounds/skin/incisions of the right foot with wound vacuum. However, there was no documented evidence of the measurement of the patient’s right foot wound. b. The ROC OASIS dated 6/30/23, showed a Jackson-Pratt tube was inserted in the right lower quadrant of the abdomen and drains into JP bulb that contained scanty, yellowish opaque “(purulent?)” fluid. However, there was no documented evidence of an assessment of the patient’s Jackson-Pratt tube site/dressing. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 14's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 3/6/22. The patient was certified for home health services during the certification periods from 3/6/22 to 5/4/22 and 5/5/2022 to 7/3/2022. The ROC OASIS dated 4/25/22, showed the patient had a wound to the left plantar foot, wound picture was taken, and the wound was cleansed and a dressing was changed. Documentation showed the wound measurement was 1.6 cm (length) x 1 cm (width). However, there was no documented evidence of the measurement of the wound depth. On 7/20/23 at 1158 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was completed at discharge for one of 18 sampled patients (Patient 9), creating the risk of not updating the patient's status for this patient. Findings: Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The POC, for the certification period from 5/25/2023 to 7/23/2023, showed from 5/25/2023 to 5/27/2023, SN visits one time every week for 1 week and from 5/28/2023 to 6/10/2023, 2 visits every week for two weeks. Review of the SN notes showed the SN conducted the visits during Week 2 (5/28/23 to 6/3/23) and Week 3 (6/4/23 to 6/10/23). On 7/17/23 at 1430 hours, an interview was conducted with the DPCS. When asked if the patient had any other home health visits after Week 3. She stated the patient had a missed discharge. She stated the SN had to do a discharge OASIS and the date was 6/9/23. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POCs were individualized and had patient-specific interventions and instructions for 12 of 18 sampled patients (Patients 3, 4, 6, 8, 9, 10, 11, 12, 13, 14, 16, and 17). These failures had the potential to negatively impact the patients’ health care outcomes. #. Review of Patient 3's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 6/8/23. The patient was certified for home health services during the certification period from 6/8/23 to 8/6/23. The SOC OASIS dated 6/8/23, showed the PCG was available daily and was able to assist in IV administration. Documentation showed the patient had a surgical wound in the right lower extremity which was not visualized by SN due to non-removable dressing and a surgical wound on the left forearm which was not visualized due to non-removable surgical dressing. The POC, for the certification period from 6/8/2023 to 8/6/2023, showed SN visits from 6/8/2023 to 6/9/2023: 1 visit every day for 2 days; from 6/8/2023 to 8/6/2023: 2 visits PRN to be used for PICC issues; and from 6/11/2023 to 7/22/2023: 2 visits every week for 6 weeks. The POC showed vital signs monitoring PRN and notify the physician for abnormal values. The POC also showed for SN to administer IV solutions/medication per physician’s order on each visit, starting 6/9/23. The POC included ertapenem (antibiotic) 1 g in 100 ml NS (10 mg/ml) infuse in 30 minutes on the patient’s right upper arm PICC. In addition, the POC showed under medication section included the information: Invanz (brand name for ertapenem) 1 g inject over 30 minutes Q 24 hours. * However, there was no documented evidence in the POC on who will be responsible for the IV antibiotic administration during non-SN days. There was no documented evidence on the indication for the PRN vital signs monitoring. There was no documented evidence on what the POC for the surgical wound in the right lower extremity and left forearm was. On 7/20/23 at 849 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. The SOC OASIS dated 5/14/23, showed the family member was able to flush the PICC and administer both antibiotic. Documentation showed the family member stated she had experience and know how to administer both antibiotic. The POC, for the certification period from 5/14/23 to 7/12/23, showed the following information: - SN visits from 5/14/2023 to 5/20/2023: 5 visits every week for 1 week; from 5/14/2023 to 7/12/2023: 4 visits PRN for disease complication; from 5/19/2023 to 7/12/2023: 5 visits PRN for wound complications; and from 5/21/2023 to 7/12/2023: 3 visits every week for 8 weeks. - SN to administer IV solutions/medication per physician’s order PRN starting 5/14/2023. The POC under the section of patient’s medications included daptomycin (antibiotic) inject 600 mg into the vein daily and ertapenem (antibiotic) 1 g in sodium chloride 0.9% 50 mL IVPB inject 1 g into the vein daily. The POC also showed diabetic foot assessment PRN -“HH Measure Wound [SN] [PRN, Start: 5/14/2023] [Measure wound weekly.]” The POC included “Negative pressure wound therapy [SN] [PRN, Start: 5/14/2023] [SN to perform dressing change to right foot diabetic foot ulcer and surgical wound Monday, Wednesday, and Friday. Dressing change to consist of: Remove old dressing (May soak with saline prior to removing as needed). Cleanse with, saline. May line wound bed with, single-layer of wide-meshed, non-adherent material, prior to placing foam. Place black foam into wound cavity. May apply, stoma paste, transparent dressing, skin prep, to periwound skin. Secure with transparent adhesive drape. Settings: Cycle- Continuous. Pressure- 125 mmHg. Intensity- Titrate to tolerance.” However, there was no documented evidence in the POC on who will be responsible for the IV antibiotic administration during non-SN days. There was no documented evidence on what the indication was the PRN diabetic foot assessment. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The POC, during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023, showed the following information: - The patient’s medication included Apply “STRATA GRT” (used to treat chronic wounds) to wound bed topically daily. - Diabetic foot assessment PRN; and to assess for cardiovascular status PRN. - For SN, to “Assess/instruct Patient/PCG on S/S of hypoglycemia/hyperglycemia, causes and treatments and consistent carbohydrate diet SN monitor patient/PCG obtained blood glucose reading and report to physician if less than 70 or greater than 250 mg/dl Diabetes managed with Oral Hypoglycemic.” - On another sentence of the POC showed for SN, “Blood glucose monitoring [SN] [PRN, Start: 6/2/2021] [SN to assess blood glucose levels or log as performed by patient/caregiver.]” However, there was no documented evidence of the wound location. There was no documented evidence on what the indication was for the PRN assessment of the patient’s diabetic foot and cardiovascular status. In addition, the POC showed inconsistency as to the frequency when blood glucose was to be monitored, if PRN or Q visit. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding #. Review of Patient 10's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 5/26/23. The patient was certified for home health services during the certification period from 5/26/23 to 7/24/23. The POC, during the certification period from 5/26/23 to 7/24/23, showed for SN to assess base knowledge level of disease and potential complications PRN and assess side effects and response to medications PRN. However, there was no documented evidence on what the indication was for the PRN assessment of the base knowledge level of disease and potential complications; and the assessment of side effects and response to medications. On 7/20/23 at 0946 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding #. Review of Patient 11's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 1/26/23. The patient was certified for home health services during the certification periods from 5/6/23 to 7/4/23 and 7/5/23 to 9/2/23. The Recert OASIS dated 5/1/23, showed the PCG was available anytime and was able to assist with administering IV medication. Documentation showed the patient had an implanted port. The POC, during the certification period from 5/6/23 to 7/4/23, showed SN visits from 5/6/2023 to 7/4/2023: 1 to 2 visits prn for port-a-cath complications; from 5/7/2023 to 7/4/2023: 1 visit every month for 3 months, from 5/28/2023 to 7/4/2023: 1 to 2 visits PRN for PICC complications; from 6/11/2023 to 7/1/2023: 1 visit every week for 3 weeks; and from 7/2/2023 to 7/4/2023: 1 visit every week for 1 week. The POC showed the patient’s medication included mepolizumab (monoclonal antibody) 100 mg/mL injection (auto-injector) inject 100 mg one time every 28 days, three injections of 100 mg each to 3 different sites SC; and heparin & NaCl lock flush IV inject 5 ml into the vein daily administer after IV antibiotic. However, there was no documented evidence on who will be responsible for the administration of mepolizumab in the POC. In addition, there was no documented evidence on what the concentration of the heparin flush was. On 7/20/23 at 1015 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 12's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 1/27/23. The patient was certified for home health services during the certification period from 5/27/23 to 7/25/23. The ROC/RECERT OASIS dated 5/25/2023, showed the patient resumed to home health care following hospitalization for pneumonia and pain. Documentation showed prior to hospitalization, patient received home health services due to the following functional deficits or limitations: the patient continued to have pain and the buttock was “nely” healed and will need to be monitored for skin breakdown in the buttock. Documentation showed the patient had a newly healed wound on coccyx. The patient needs HHA to help with the personal needs. The POC, during the certification period from 5/27/23 to 7/25/23, showed SN visits from 5/27/2023 to 5/27/2023, 1 visit every week for 1 week; from 5/28/2023 to 6/10/2023, 2 visits every week for 2 weeks; and from 6/11/2023 to 7/8/2023, 1 visit every week for 4 weeks. The POC showed vital signs monitoring PRN, assess gastrointestinal system PRN, and assess respiratory status PRN. The POC showed “Wound care [SN] [PRN Start: 1/27/2023] [Wound Type ulceration due to Pressure; Location sacrococcyx/Left buttock;” The POC also included the following wound care orders: cleanse with saline or moist wipes, apply Calazime barrier paste; ok to apply “sacral Mepilex” (wound dressing) as needed; twice daily and as needed. However, there was no documented evidence on what the indication was for the PRN assessment of the gastrointestinal and respiratory system, and vital signs monitoring. There was no documented evidence in the POC on who will be responsible for the care of sacrococcyx/Left buttock when SN would not perform the treatment. On 7/20/23 at 1049 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 13's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 6/19/22. The patient was certified for home health services during the certification period from 6/19/22 to 8/17/22. The POC, during the certification period from 6/19/22 to 8/17/22, showed SN visits from 6/19/2022 to 6/25/2022, 3 visits every week for 1 week; from 6/19/2022 to 8/17/2022, 2 visits PRN visits for change in patient condition; from 6/26/2022 to 7/16/2022, 2 visits every week for 3 weeks; and from 7/17/2022 to 7/30/2022, 1 visit every week for 2 weeks. The POC showed vital signs monitoring PRN, assess for cardiovascular status and respiratory status PRN. The POC showed the patient’s medication included hydrocortisone (corticosteroid) 2.5% cream apply thin film to affected area two to four times daily PRN. However, there was no documented evidence on what the indication was for the PRN assessment of the gastrointestinal and respiratory system; and vital signs monitoring. In addition, there was no documented evidence the indication for the PRN use of hydrocortisone. On 7/20/23 at 1109 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 14's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 3/6/22. The patient was certified for home health services during the certification periods from 3/6/22 to 5/4/22 and 5/5/2022 to 7/3/2022. a. The SOC OASIS dated 3/6/2022, showed the nutritional requirement was enteral diet. Documentation showed the patient was instructed in site care, change of appliance, stoma care, enteral feeding schedule, signs and symptoms of infection and to notify RN/physician. The patient and/or caregiver verbalized understanding. Documentation showed primary reason nursing was ordered was G-tube management and instruction to patient on how to use and care. The POC, during the certification period from 3/6/22 to 5/4/22, showed the nutritional requirement included enteral diet. The POC showed SN visit from 3/6/2022 to 3/19/2022, 2 visits every week for 2 weeks for teaching/instruct patient and/or PCG in G-tube care, and how to feed through the G-tube; from 3/6/2022 to 5/4/2022, 1 to 4 visits PRN for G-tube emergency needs; and from 3/20/2022 to 4/30/2022, 1 visit every week for 6 weeks for G-tube care. The POC showed to vital signs monitoring PRN and assess for diabetic manifestations and diabetic complications PRN. However, there was no documented evidence on the specific information of the patient’s enteral diet such as formula and water flush if any. In addition, there was no documented evidence on the information on how to care for the G-tube site and how often. There was no documented evidence on what the indication was for the PRN assessment of vital signs monitoring and assessment for diabetic manifestations and diabetic complications. On 7/20/23 at 1159 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. b. The Recert OASIS dated 5/4/22, showed the patient had a PICC. The patient had a bilateral upper gluteal pressure injury. Documentation showed dressing changed “foam.” Documentation showed the dressing was dry and intact. The POC, for the certification period 5/5/2022 to 7/3/2022, showed no documented evidence on what the POC for the patient’s PICC was. There was no documented evidence on what the POC for the bilateral upper gluteal pressure injury. On 7/20/23 at 1159 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 17's closed clinical record was initiated on 7/12/23. The clinical record showed the SOC was 2/23/22. The patient was certified for home health services during the certification period from 2/23/22 to 4/23/33. The POC, during the certification period from 2/23/22 to 4/23/33, showed the following information: - vital signs monitoring PRN - assess and instruct nutritional needs for wound PRN - assess lower extremity for skin integrity PRN, measure wound PRN, - wound care PRN on patient’s left upper arm and left forearm wound. Cleanse with normal saline, apply Xeroform (wound dressing), cover with nonadherent gauze, and Kerlix, secure with tape two times per week - wound care PRN to gluteal cleft and right buttocks. Cleanse with wound cleanser, apply Medi-honey (wound dressing, cover with foam dressing, two times per week However, there was no documented evidence on what the indication was for the PRN on the above orders. On 7/20/23 at 1149 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. Review of the agency's P&P titled Care Planning Process dated 7/2023 showed based on the assessment and conclusions, the plan of care will include, but not be limited to patient specific interventions and education; all patient care orders from all providers involved in the plan of care, including verbal orders; identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements; specific services and treatments to be provided, including services furnished via telecommunication systems (if appropriate); and patient and caregiver education and training to facilitate timely discharge. 1. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification period from 6/24/23 to 8/22/23. The POC, for the certification period from 6/24/23 to 8/22/23, showed to instruct the patient/caregiver in signs and symptoms of infection and when to report to the skilled nurse/physician. However, there was no documented evidence showing the specific signs and symptoms of infection the patient/caregiver should beware of in order to notify the SN or physician. On 7/20/23 at 0920 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 2. Review of Patient 8's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 12/30/22. The patient was certified for home health services during the certification period from 4/29/23 to 6/27/23 and 6/28/23 to 8/26/23. The POC, for the certification period from 4/29/23 to 6/27/23, showed the patient’s nutritional requirements included diabetic diet and GT feeding. However, the POC did not specify the type and amount of feeding the patient required. The POC, for the certification period from 6/28/23 to 8/26/23, showed the patient’s nutritional requirements included “other: tube feeding only.” However, the POC did not specify the type and amount of feeding the patient required. On 7/20/23 at 1015 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 3. Review of Patient 16's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification period from 12/22/22 to 2/19/23. The POC, for the certification period from 12/22/22 to 2/19/23, showed to monitor the patient’s vital signs and to “notify MD vs. outside company parameters.” However, the POC did not specify the specific parameters and when to notify the physician. On 7/20/23 at 1100 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged finding.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician's order was dated accurately for one of 18 sampled patients (Patient 9). This posed the risk for not providing appropriate, consistent, and quality care to the patient. Findings: The agency's P&P titled CA Physician Participation in Plan of Care dated 08/21 showed when services are provided on the basis of a physician’s (or other authorized licensed independent practitioner) verbal orders, a registered nurse, or other qualified personnel responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patent’s clinical record, and sign, and date, and time the orders. The attending physician (or other authorized licensed independent practitioner) will sign the individualized plan of care /treatment within 30 days of the start of care, unless otherwise specified by applicable state law and regulation. Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The SN note dated 4/17/23, showed the patient was awake, alert, and oriented x4. Documentation showed the patient’s right dorsal foot wound was dry, clean, slough, and unable to visualize the base. Documentation showed new wound treatment was updated, “clean wound with NS, cover with dry gauze, foam.” The physician’s order dated 4/18/23, showed SN to perform/teach the patient/PCG on wound care for the right medial dorsal foot wound. The physician’s order showed to cleanse wound with NS; do not scrub or use excessive force at the time of dressing change; apply dry gauze and cover with a foam dressing Q day. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the date of the physician’s order should have been 4/17/23, instead of 4/18/23. She was informed and acknowledged the finding.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to revise and update the POC for two of 18 sampled patients (Patients 6 and 18), creating the risk for not providing necessary care and services to meet the care needs for these patients. Findings: 1. Review of Patient 18’s clinical record was initiated on 7/17/23. The clinical record showed the SOC was 1/21/23. The patient was certified for home health services during the certification period from 5/21/23 to 7/19/23. The Recert OASIS completed by the PT dated 5/18/23, showed the patient did not have unhealed pressure injury at Stage 2 or higher. Documentation showed under integumentary status as asymptomatic. The SN note dated 5/19/23, showed not applicable related to wound care. Documentation showed no further skilled nursing needs at this time. The POC, for the certification period from 5/21/23 to 7/19/23, showed SN wound care each visit. The POC included SN to clean open wound on the lower back with normal saline, pat dry apply Medihoney (wound dressing) to wound bed and cover with a foam dressing every other day until wound is closed. Documentation showed the PCG would be able to perform wound care if no SN visit. However, there was no documented evidence the POC was updated for the skilled nursing services which were no longer needed for wound care on the patient’s lower back. On 7/20/23 at 1103 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. The POC, for the certification period from 5/14/23 to 7/12/23, showed the following information: - SN visits from 5/14/2023 to 5/20/2023, five visits every week for one week; from 5/14/2023 to 7/12/2023, four visits PRN for disease complication; from 5/19/2023 to 7/12/2023, five visits PRN for wound complications; and from 5/21/2023 to 7/12/2023, three visits every week for eight weeks. -“HH Measure Wound [SN] [PRN, start: 5/14/2023] [Measure wound weekly.]” The POC included “Negative pressure wound therapy [SN] [PRN, start: 5/14/2023] [SN to perform dressing change to right foot diabetic foot ulcer and surgical wound Monday, Wednesday, and Friday. Dressing change to consist of: Remove old dressing (May soak with saline prior to removing as needed). Cleanse with saline. May line wound bed with single-layer of wide-meshed, non-adherent material, prior to placing foam. Place black foam into wound cavity. May apply, stoma paste, transparent dressing, skin prep, to peri wound skin. Secure with transparent adhesive drape. Settings: Cycle- Continuous. Pressure- 125 mmHg. Intensity- Titrate to tolerance.” a. The Transfer Without Discharge Oasis dated 6/6/23, showed the patient was admitted to the acute care hospital following a vascular procedure. The ROC OASIS dated 6/11/23, showed the patient had one observable surgical wound. Documentation showed the patient resumed home health care following a hospitalization for possible heart surgery. Documentation showed prior to hospitalization, the patient received home health services due to the following functional deficits or limitations: PICC line in place, IV antibiotic, wound vacuum on open wound of the right foot. Documentation showed the patient presented with mobility issues: unsteady gait due to the open wound of the foot, PICC line of the right upper arm, and wound vacuum of the right foot. The telephone order dated 6/11/23, showed a change of visit order for skilled nursing which included from 6/11/2023 to 6/17/2023, four visits every week for one week for wound vacuum dressing change; from 6/11/2023 to 7/12/2023, one to three visits as needed for IV or wound vacuum issues; from 6/18/2023 to 7/8/2023, three visits every week for three weeks for wound vacuum dressing change; and from 7/9/2023 to 7/12/2023, two visits every week for one week. However, there was no documented evidence the POC was updated to address the physician’s order for the patient’s wound care for the right foot after the patient’s resumption of care assessment. b. The Transfer Without Discharge Oasis dated 6/26/23, showed the patient was admitted to the acute care hospital due to a ruptured appendicitis. The ROC OASIS dated 6/30/23, showed a Jackson-Pratt tube was inserted in the right lower quadrant of the abdomen and drains into “JP” bulb that contained scanty yellowish opaque “(purulent?)” fluid. The telephone order dated 7/1/23, showed a change for skilled nursing visit: one visit every week for one week from 6/30/2023 to 7/1/2023; three visits every week for one week from 7/2/2023 to 7/8/2023; and two visits every week for one week from 7/9/2023 to 7/12/2023. The telephone order dated 7/7/23, showed to cleanse s/p appendectomy drain surgical site with wound cleanser, pat dry, apply Biopatch (antimicrobial agent) or HaloGuard (antimicrobial agent) or equivalent, cover with transparent dressing, weekly and PRN if soiled or dislodged. However, there was no documented evidence of an updated POC to address the patient's Jackson-Pratt site until 7/7/23. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.

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 record review and interview, the agency failed to coordinate the care to meet the patients' care needs for nine of 18 sampled patients (Patients 7, 8, 9, 10, 11, 12, 14, 15, and 16). This failure created the risk of not providing the necessary care and services to these patients. #. Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The POC, for the certification period from 5/25/2023 to 7/23/2023, showed SN visits from 5/25/2023 to 5/27/2023, 1 visit every week for 1 week and from 5/28/2023 to 6/10/2023, 2 visits every week for 2 weeks. Review of the SN notes showed there was no visit instead of one for Week 1 (5/25/23 to 5/27/23). There was no documented evidence the physician was notified that there was no visit instead of one for Week 1. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. She stated there was one missed visit for Week 1. When asked if the missed visit was coordinated with the physician. The DPCS stated there was no coordination of the missed visit with the physician. She was informed and acknowledged the finding. #. Review of Patient 10's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 5/26/23. The patient was certified for home health services during the certification period from 5/26/23 to 7/24/23. The PT note dated 6/8/20, showed the patient had a 8/10 (0 = no pain and 10 = worst pain) sharp stabbing pain on the right shin. Documentation showed blank under relief measures. There was no documented evidence the patient’s pain was reassessed. However, there was no documented evidence the patient’s 8/10 pain was coordinated with the RN or the physician. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 11's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 1/26/23. The patient was certified for home health services during the certification periods from 5/6/23 to 7/4/23 and 7/5/23 to 9/2/23. The Recert OASIS dated 5/1/23, showed sharp 9/10 port-a cath site pain. Documentation showed blank under relief measures. There was no documented evidence the patient’s pain was reassessed. Documentation showed there was a new order from the physician for SN to draw blood for blood cultures on 5/1/23, one set from port catheter and one set from peripheral with the diagnosis of port-a- cath infection. Review of a prescription order dated 5/1/23, showed blood culture two sets one from the “peripheral” and one from the “port” with the diagnosis of port/catheter infection However, there was no documented evidence the SN coordinated with the physician to address the 9/10 pain the patient had at the time of the visit. On 7/20/23 at 1015 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 12's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 1/27/23. The patient was certified for home health services during the certification period from 5/27/23 to 7/25/23. a. The PT Evaluation dated 6/29/2023, showed 8/10 left knee pain. Documentation showed blank under relief measures. There was no documented evidence the patient’s pain was reassessed. However, there was no documented evidence the patient’s 8/10 pain was coordinated with the RN or the physician. b. The SN Missed Visit note dated 6/1/2023, showed the family member was going to meet at the house after work; but was delayed at work and did not make it home. Further review of the clinical record showed no documented evidence the physician was notified of the missed visit. On 7/20/23 at 1049 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. She stated there was no notification of the physician of the missed visit. #. Review of Patient 14's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 3/6/22. The patient was certified for home health services during the certification periods from 3/6/22 to 5/4/22 and 5/5/2022 to 7/3/2022. The POC, during the certification period from 3/6/22 to 5/14/22, showed SN visits from 3/6/2022 to 3/19/2022, 2 visits every week for 2 weeks for teaching/instruct patient and/or PCG in G-tube care, and how to feed through the g-tube; from 3/6/2022 to 5/4/2022, 1 to 4 visits PRN for G-tube emergency needs; and from 3/20/2022 to 4/30/2022, 1 visit every week for 6 weeks for G-tube care. The SN Missed Visit note dated 3/12/22, showed the SN was unable to contact the patient. However, there was no documented evidence the physician was notified of the missed visit. On 7/20/23 at 1158 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. Review of the agency's P&P titled Care Coordination dated 2/2023 showed care coordination will include, but not be limited to, communication among home health team members and any additional care services not provided by home health will be documented timely in case communications or clinical notes; coordinate communication with all providers (or other authorized licensed independent practitioner) involved in the plan of care; and integrate orders from all providers (or other authorized licensed independent practitioner), and additional care services (e.g. infusion pharmacy, transitional medical clinic, ambulatory case management, etc.) involved in the plan of care. 1. Review of Patient 7's clinical record was initiated on 7/11/23. The clinical record showed the SOC was 5/4/23. The patient was certified for home health services during the certification period from 5/4/23 to 7/2/23. Review of the clinical record showed the PT visited the patient’s home on 6/10/23. A PT Prescription dated 6/8/23 was scanned as part of the patient’s clinical record with orders to provide range of motion exercises, scapular stabilization, strengthening exercises, and stretching. The order showed electrical muscle stimulation as the modality. The frequency showed to perform the services two to three times per week for six weeks. Further review of the clinical record showed no documented evidence the above orders were included in the patient’s POC nor was there any documentation showing this was communicated to the patient’s interdisciplinary team. On 7/20/23 at 1005 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 2. Review of Patient 8's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 12/30/22. The patient was certified for home health services during the certification periods from 4/29/23 to 6/27/23 and 6/28/23 to 8/26/23. Review of the SN Recert OASIS dated 4/24/23, showed the SN documented the patient’s blood pressure to be 161/74. Further review of the clinical record showed no documented evidence showing the patient’s blood pressure was reassessed or if the physician was notified. On 7/20/23 at 1015 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 3. Review of Patient 15's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 9/13/22. The patient was certified for home health services during the certification period from 11/12/22 to 12/10/22. Review of the PT Repeat Visit notes dated 11/16/22, showed the PT documented the patient’s blood pressure to be 88/62. Further review of the clinical record showed no documented evidence showing the patient’s blood pressure was reassessed or if the physician was notified. On 7/20/23 at 1045 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 4a. Review of Patient 16's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification period from 12/22/22 to 2/19/23. The POC, for the certification period from 12/22/22 to 2/19/23, showed to monitor the patient’s vital signs and to “notify MD vs. outside company parameters.” However, the POC did not specify the specific parameters and when to notify the physician. Cross Reference G 574, example #3. Review of the SN Repeat Visit notes dated 12/27/22, showed the SN documented the patient’s heart rate to be 114. Further review of the clinical record showed no documented evidence showing the patient’s heart rate was reassessed or if the physician was notified. b. The POC, for the certification period from 12/22/22 to 2/19/23, showed to monitor and address the patient’s pain using the numerical pain scale. Review of the PT Repeat Visit notes dated 12/22/22, showed the PT assessed the patient’s pain to be 9/10. Further review of the clinical record showed no documented evidence showing the patient’s pain was reassessed, addressed, or if the physician was notified. On 7/20/23 at 1045 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions on the SN visit schedule for three of 18 sampled patients (Patients 1, 4, and 7), creating the risk of not providing the necessary information to these patients. X. Review of Patient 1's clinical record was initiated on 7/7/23. The clinical record showed the SOC was 2/9/23. The patient was certified for home health services during the certification periods from 2/9/23 to 4/9/23, 4/10/23 to 6/8/23, and 6/9/23 to 8/7/23. The POC, for the certification periods from 6/9/23 to 8/7/23, cited three SN visits every week for seven weeks for wound care, and three visits as needed for wound complications. On 7/7/23 at 0915 hours, a joint home visit with LVN 1 was conducted to Patient 1's home. LVN 1 was asked for the written instructions on the SN visit schedule. Review of the written instruction on the SN visit was blank. LVN 1 stated they did not fill out the calendar and added they would call the patient or family member prior to the visit. LVN 1 was informed and acknowledged the finding. On 7/20/23 at 1140 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. X. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification period from 6/24/23 to 8/22/23. The POC, for the certification period from 6/24/23 to 8/22/23, cited one SN visit every week for seven weeks and three PRN visits for catheter complications. The POC also cited two PT visits every week for three weeks. On 7/10/23 at 0900 hours, a joint home visit was conducted with PT 1 to Patient 4’s home. PT 1 was asked to show the written instructions outlining the SN and PT visit schedules. PT 1 showed the calendar; however, it was blank. Further review of the patient’s admission packet provided by the agency showed no documented evidence of the written instructions outlining the SN visit schedules. On 7/10/23 at 1028 hours, an interview and concurrent record review was conducted with PT 1. PT 1 was informed and acknowledged the finding. X. Review of Patient 7's clinical record was initiated on 7/11/23. The clinical record showed the SOC was 5/4/23. The patient was certified for home health services during the certification period from 7/3/23 to 8/31/23. The POC, for the certification period from 7/3/23 to 8/31/23, cited two OT and PT visits every week for three weeks. On 7/10/23 at 1200 hours, a joint home visit was conducted with OT 1 to Patient 7’s home. OT 1 and Patient 7 were asked to show the written instructions outlining the OT and PT visit schedules. Patient 7 verified the agency did not provide him with written instructions of the visits; instead, the staff called ahead of time to inform him when they will come and he would write it down in his personal calendar as a reminder. On 7/10/23 at 1252 hours, an interview was conducted with OT 1. OT 1 was informed and acknowledged the finding.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide the name and information of the clinical manager for two of 18 sampled patients (Patients 4 and 5). This failure created the risk of not providing the necessary information to these patients. Findings: 1. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification period from 6/24/23 to 8/22/23. The POC, for the certification period from 6/24/23 to 8/22/23, cited one SN visit every week for seven weeks and three PRN visits for catheter complications. The POC also cited two PT visits every week for three weeks. On 7/10/23 at 0943 hours, a joint home visit was conducted with PT 1 to Patient 4’s home. Review of the patient's admission packet provided by the agency showed no documented evidence of the name and contact information of the agency's clinical manager. On 7/10/23 at 1028 hours, an interview and concurrent clinical record review was conducted with PT 1. PT 1 was informed and acknowledged the finding. 2. Review of Patient 5's clinical record was initiated on 7/11/23. The clinical record showed the SOC was 6/30/23. The patient was certified for home health services during the certification period from 6/30/23 to 8/28/23. The POC, for the certification period from 6/30/23 to 8/28/23, cited one SN visit every week for five weeks and three PRN visits for catheter complications. The POC also cited one PT visit every week for three weeks; one OT visit every week for two weeks from 7/5/23 to 7/15/23; and two CHHA visits every week for four weeks. On 7/11/23 at 0800 hours, a joint home visit was conducted with CHHA 1 to Patient 5’s home. Review of the patient's admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA's clinical manager. On 7/11/23 at 0840 hours, an interview and concurrent clinical record review was conducted with CHHA 1. CHHA 1 was informed and acknowledged the finding.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to implement infection control practices related to hand hygiene and catheter care for four of 18 sampled patients (Patients 2, 3, 4, and 5), creating the risk of the spread of infection. #. Review of Patient 3's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 6/8/23. The patient was certified for home health services during the certification period from 6/8/23 to 8/6/23. The POC, for the certification period from 6/8/2023 to 8/6/2023, showed SN visits from 6/8/2023 to 6/9/2023: 1 visit every day for 2 days; from 6/8/2023 to 8/6/2023: 2 visits PRN to be used for PICC issues; and from 6/11/2023 to 7/22/2023: 2 visits every week for 6 weeks. The POC showed IV dressing included to change Opsite (transparent adhesive dressing) without gauze dressing change Q seven days after insertion then weekly and PRN. A joint home visit with RN 2 was conducted on 7/10/23 at 0800 hours, to Patient 3's home. The following was observed: -RN 2 donned sterile glove. PICC line site on the right upper arm was cleaned and dressing change was performed. RN 2 gathered the used items for PICC line dressing change. - RN 2 doffed her gloves without performing hand hygiene, then donned new gloves. RN 2 performed PICC line cap change. On 7/10/23 at 0900 hours, an interview was conducted with RN 2 and was informed of the finding. On 7/20/23 at 0849 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the finding. XX. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification period from 6/24/23 to 8/22/23. The POC, for the certification period 6/24/23 to 8/22/23, showed the patient had a history of UTI and had an indwelling catheter. The POC also cited two PT visits every week for three weeks. On 7/10/23 at 0943 hours, a joint home visit was conducted with PT 1 to Patient 4’s home. Upon arrival, the patient was observed lying in bed with an indwelling catheter. The catheter bag was observed inside the trash container, on the right side of the bed. There was no trash inside the container. PT 1 performed hand hygiene and a donned new pair of gloves prior to providing services. After assisting the patient with the exercises, PT 1 discarded his gloves in the trash container where the patient’s catheter bag was located. On 7/10/23 at 1028 hours, an interview was conducted with PT 1. PT 1 was informed and acknowledged the finding. XX. Review of Patient 5's clinical record was initiated on 7/11/23. The clinical record showed the SOC was 6/30/23. The patient was certified for home health services during the certification period from 6/30/23 to 8/28/23. On 7/11/23 at 0800 hours, a joint home visit was conducted with CHHA 1 to Patient 5’s home. Prior to assisting the patient in the shower, CHHA 1 performed hand hygiene and donned a new pair of gloves. CHHA 1 helped wash the patient’s hair and body. After the shower, without changing gloves and washing hands, CHHA 1 proceeded to help the patient dry herself with a clean towel, change into new clothes, and put lotion on the patient’s back. On 7/11/23 at 0840 hours, an interview was conducted with CHHA 1. CHHA 1 was informed and acknowledged the finding. According to CDC, the Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient’s immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal In addition, the CDC recommend a routine in cleaning and reprocessing of reusable medical equipment prior to use on another patient or when soiled and to maintain separation between clean and soiled equipment to prevent cross contamination. X. Review of Patient 2's clinical record was initiated on 7/7/23. The clinical record showed the SOC was 11/4/22. The patient was certified for home health services during the period from 5/3/23 to 7/1/23 and 7/2/23 to 8/30/23. The POC, for the certification period from 7/2/23 to 8/30/23, cited SN visits two visits every week for eight weeks, and three visits as needed for wound complications. The POC included wound treatment to the right hallux amputation post revision as follows: cleanse the Puracyn wash, apply Adaptic contact layer with triple antibiotic ointment, 1/4 iodoform packing to the plantar lateral aspect of wound, cover with gauze, apply ABD pad over plantar part of foot, secure with kerlix, then cast padding, then ACE wrap. Change three times a week and as needed. A joint home visit with RN 1 was conducted on 7/7/23 at 1100 hours, to Patient 2's home. The following was observed: RN 1 donned gloves. RN 1 used trauma shears and removed the soiled wound dressing from the patient’s right foot, and placed the trauma shears down before measuring the wound. RN 1 doffed her gloves and performed hand hygiene. RN 1 donned gloves, cleansed the wound, and patted the wound dry. RN 1 removed the iodoform packing from the bottle, and used the trauma shears to cut the packing strip before placing the packing strip into the wound. RN 1 then proceeded to apply triple antibiotic ointment to the wound, and covered the wound with adaptic dressing, gauze, an ABD pad, and wrapped with kerlix gauze and an ACE wrap. * RN 1 failed to clean the scissors after removing the soiled wound dressing. On 7/7/23 at 1145 hours, and interview was conducted with RN 1 and was informed of the findings. On 7/20/23 at 1140 hours, an interview was conducted with the QM Nurse, The QM Nurse was informed of the finding.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to accurately report the infection control data and analyze the different types of infection. This failure created the risk of not identifying the appropriate action plans for infection control practices. Findings: Review of the agency's P&P titled Infection Control Program/Plan Home Health dated 12/2020 showed surveillance is performed and includes (but is not limited to) compiling and analyzing surveillance data, presenting findings and making recommendations to the Quality Council and investigating trends of infections, clusters, and unusual infections. The summary, analysis, and trending infection surveillance findings will be presented quarterly to Quality Council through QAPI. Review of the agency’s infection control program for 2019 to 2022 was conducted on 7/19/23. The infection control program for 2019 to 2022 showed the agency had collected the total number of patient infection occurrences for each quarter. However, further review of the infection control program showed the total number of patient infection occurrences was not reported accurately during the quarterly meetings. For example, review of the 2020 Infection Control Log for the first quarter showed there were three integumentary, zero respiratory, one gastrointestinal, and five genitourinary cases reported. However, review of the QAPI Meeting Minutes for the first quarter dated 4/30/20, showed the team discussed the infection report in which there were 16 cases of UTIs, eight wounds, one CDIFF, two respiratory, one influenza, and one COVID related case which were inconsistent with the data collected from the infection control log. In addition, there was no documented evidence showing the agency had analyzed the different types of infection to determine their causes. Review of the QAPI Meeting Minutes for 2019 to 2022 showed the committee only focused on the UTI and COVID related cases. On 7/20/23 at 1130 hours, an interview and concurrent record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the care and services were provided in accordance with the POC for 10 of 18 sampled patients (Patients 1, 2, 4, 7, 8, 12, 14, 15, 16, and 17). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. #. Review of Patient 12's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 1/27/23. The patient was certified for home health services during the certification period from 5/27/23 to 7/25/23. The POC, during the certification period from 5/27/23 to 7/25/23, showed SN visits from 5/27/2023 to 5/27/2023, 1 visit every week for 1 week; from 5/28/2023 to 6/10/2023, 2 visits every week for 2 weeks; and from 6/11/2023 to 7/8/2023, 1 visit every week for 4 weeks. Review of the clinical record no show documented evidence the SN conducted a visit on Week 1 (5/27/23), instead of one visit. On 7/20/23 at 1049 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 14's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 3/6/22. The patient was certified for home health services during the certification periods from 3/6/22 to 5/4/22 and 5/5/2022 to 7/3/2022. The POC, during the certification period from 3/6/22 to 5/4/22, showed SN visits from 3/6/2022 to 3/19/2022, 2 visits every week for 2 weeks for teaching/instruct patient and/or PCG in G-tube care, and how to feed through the G-tube; from 3/6/2022 to 5/4/2022, 1 to 4 visits PRN for G-tube emergency needs; and from 3/20/2022 to 4/30/2022, 1 visit every week for 6 weeks for G-tube care. a. Review of the SN notes showed no documented evidence the SN had a visit on Week 5 (4/3/22 to 4/9/22) and Week 6 (4/10 to 4/16/22), instead of one as per the POC. On 7/20/23 at 1158 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 17's closed clinical record was initiated on 7/12/23. The clinical record showed the SOC was 2/23/22. The patient was certified for home health services during the certification period from 2/23/22 to 4/23/33. The POC, during the certification period from 2/23/22 to 4/23/33, showed the following information: - wound care PRN on patient’s left upper arm and left forearm wound. Cleanse with normal saline, apply Xeroform (wound dressing), cover with nonadherent gauze, and Kerlix, secure with tape two times per week - wound care PRN to gluteal cleft and right buttocks. Cleanse with wound cleanser, apply Medi-honey (wound dressing, cover with foam dressing, two times per week a. The SN note dated 2/25/22, showed the skin tear on the left lower arm was cleansed with wound cleanser, applied antibiotic, Steri-trips (wound enclosure), gauze and wrapped with Kerlix. Documentation showed the right medial buttock was cleansed with wound cleanser, applied Medihoney and covered with foam. Documentation showed barrier film was applied to the periwound. However, there was no documented evidence for the use of antibiotic for the skin tear on the left lower arm in the POC. There was no documented evidence for the use of the barrier film in the POC. On 7/20/23 at 1149 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. b. The SOC OASIS dated 2/23/22, showed the patient had a left lower lateral leg lesion which had a measurement of 1.5 cm (length) x 1 cm (width). Documentation showed the wound was dry, intact and was open to air. The SN note dated 2/25/22, showed the patient had a left lower lateral leg lesion. Documentation showed the lesion was cleansed with wound cleanser and was open to air. The SN note dated 3/4/22, showed the patient had left lower lateral leg lesion showed 1.5 cm x 1 cm and was open to air. The SN note dated 3/23/22, showed left lower lateral leg lesion was a white cyst like growth that was easily removed with gauze. Documentation showed left lower lateral leg lesion was cleansed with wound cleanser and the dressing was with a gauze and Xeroform (wound dressing). However, there was no documented evidence on what the POC was for the left lateral leg lesion. On 7/20/23 at 1149 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 1. Review of Patient 1's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/9/23. The patient was certified for home health services during the certification period from 4/10/23 to 6/8/23. The POC, for the certification period from 4/10/23 to 6/8/23, showed to clean the mid abdominal wound with wound cleanser and normal saline. The POC showed to measure the wound weekly. Review of the SN Visit notes during the certification period showed there were multiple dates where the patient’s wound was not cleaned and measured as cited in the POC. For example, review of the SN Repeat Visit note dated 5/5/23, showed the wound was only cleaned with sterile normal saline. There was no documented evidence showing the SN cleaned the wound with a wound cleanser. In addition, review of the SN notes for Week 4 dated 5/1, 5/3, and 5/5/23, showed no documented evidence of the wound measurements. On 7/20/23 at 0834 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed of the finding. 2a. Review of Patient 2's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 11/4/22. The patient was certified for home health services during the certification periods from 5/3/23 to 7/1/23 and 7/2/23 to 8/30/23. The POC, for the certification periods from 5/3/23 to 7/1/23 and 7/2/23 to 8/30/23, showed to monitor the patient’s vital signs and notify the physician if the heart rate was greater than or equal to 100 and if the SBP is less than 90 or greater than or equal to 160 mmHg, or if the patient was symptomatic. Review of the SN Repeat Visit note dated 6/30/23, showed the patient’s blood pressure was 168/86. Review of the SN Repeat Visit note dated 7/7/23, showed the patient’s heart rate was 104. Further review of the clinical record showed no documented evidence the patient’s blood pressure and heart rate were reassessed. In addition, there was no documented evidence showing the physician was notified of the vital signs outside of the parameters as cited in the POC. b. The POC, for the certification period from 5/3/23 to 7/1/23, showed to clean the patient’s right hallux wound with Puracyn (antimicrobial cleanser) wash three times per week and PRN. Review of the SN Visit notes showed there were multiple dates where the patient’s wound was not cleaned as cited in the POC. For example, review of the SN Repeat Visit note dated 6/14/23, showed the wound was cleaned with a wound cleanser. However, there was no documented evidence showing the specific type of wound cleanser used. On 7/20/23 at 0858 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the findings. The QM Nurse verified the staff should have documented the specific type of wound cleanser used. 3a. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification period from 4/25/23 to 6/23/23. The POC, for the certification period from 4/25/23 to 6/23/23, showed the following wound care orders: -Clean the patient’s right lower leg wound with wound cleanser, apply xeroform (non-adherent dressing), cover with bordered foam two times per week, and measure the wound weekly. -Clean the patient’s left lower leg wound with wound cleanser, apply bordered foam two times per week, and measure the wound weekly. Review of the SN Visit notes showed there were multiple dates where the patient’s wounds were not measured weekly or cleaned as cited in the POC. For example, review of the SN Repeat Visit note dated 4/28/23, showed both wounds were cleaned with sterile normal saline instead of the wound cleanser as cited in the POC. Review of the SN Repeat Visit note dated 5/18/23, showed no documented evidence the wounds were measured. b. The POC, for the certification period from 4/25/23 to 6/23/23, showed to change the catheter every three weeks. Review of the SN SOC OASIS dated 4/25/23, showed the patient’s catheter was placed on 4/21/23 and was due to be changed on 5/12/23. However, review of the clinical record, revealed no documented evidence showing the patient’s catheter was changed on 5/12/23 or every three weeks as cited in the POC. c. The POC, for the certification period from 4/25/23 to 6/23/23, cited two PT visits every week from 5/1/23 to 5/27/23. However, review of the PT visit notes, showed the PT only visited the patient once a week for Week 3 (5/7/23 to 5/13/23) and Week 5 (5/21/23 to 5/27/23). On 7/20/23 at 0920 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 7/11/23. The clinical record showed the SOC was 5/4/23. The patient was certified for home health services during the certification period from 5/4/23 to 7/2/23. Review of the physician’s order dated 6/4/23, cited two PT visits every week for three weeks from 6/4/23 to 6/24/23 and two OT visits every week for two weeks from 6/11/23 to 6/24/23. However, review of the OT and PT visit notes, showed the OT and PT only visited once during Week 8 (6/18/23 to 6/24/23). The OT visited on 6/19/23 and the PT visited on 6/22/23. On 7/20/23 at 0920 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 5a. Review of Patient 8's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 12/30/22. The patient was certified for home health services during the certification periods from 4/29/23 to 6/27/23 and 6/28/23 to 8/26/23. The POC, for the certification period from 4/29/23 to 6/27/23, showed for the SN to perform bladder irrigations weekly. Review of the SN Repeat Visit notes showed there were multiple dates where the SN did not perform bladder irrigation weekly as cited in the POC. For example, on 5/2/23, there was no documented evidence showing the bladder irrigation was performed. There was also no check mark next to the care plan showing the intervention was completed. b. The POC, for the certification period from 6/28/23 to 8/26/23, showed the patient had an upper abdominal wound and for the SN to clean the wound using the wound cleanser, apply antifungal powder to the periphery, apply Marathon (liquid skin protectant) to the crust, cover with zinc based barrier cream, cover with gauze, and then secure with tape. The POC showed to measure the wound weekly. However, review of the SN Repeat Visit note dated 7/5/23, showed the wound was cleansed with sterile normal saline instead of the wound cleanser. There was also no documented evidence showing the wound was measured. On 7/20/23 at 1015 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the findings. 6. Review of Patient 15's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 9/13/22. The patient was certified for home health services during the certification period from 11/12/22 to 12/10/22. The POC, for the certification period from 11/12/22 to 12/10/22, cited one to two PT visits every week for four weeks from 11/13/22 to 12/10/22. However, review of the clinical record showed no documented evidence the PT visited the patient’s home for Week 3 (11/27/22 to 12/3/22). On 7/20/23 at 1045 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding. 7. Review of Patient 16's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification period from 12/22/22 to 2/19/23. The POC, for the certification period from 12/22/22 to 2/19/23, showed to clean the patient’s wound on the buttocks with wound cleanser, then apply a thin layer of Strata ointment and leave open to air one to two times per day. The POC showed to measure the wound weekly. Review of the clinical record showed multiple dates where the wound was not cleaned and measured as cited in the POC. For example, on 12/27/22, the interventions showed the dressing was changed and cleaned by the SN using saline. The wound was patted dry, and foam was applied and secured using paper tape which was inconsistent with the POC. In addition, there was no documented evidence showing the wound was measured. On 7/20/23 at 1100 hours, an interview was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate and complete clinical notes for 11 of 18 sampled patients (Patients 1, 4, 6, 9, 10, 11, 12, 13, 14 16, and 17). This failure created the increased risk of substandard healthcare outcomes to these patients. #. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. a. The SN note dated 5/22/23 showed the patient’s last BM was 5/21/23; the SN note dated 5/24/23, showed the patient’s last BM was 5/24/23; the SN note dated 5/26/23, showed the patient’s the last BM was 5/26/23; the SN note dated 5/27/23, showed the patient’s last BM was 5/27/23; and on 5/29/23, the patient’s last BM was 5/29/23. However, the SN note dated 5/31/23, showed no documented evidence the patient’s last BM was completed. b. The SN note dated 6/21/23, showed the patient’s right foot was cleansed with the wound cleanser. On another section of the note showed the SN performed dressing change on the right foot ulcer. Documentation showed the dressing change consisted of removing the old dressing “(May soak with saline prior to removing as needed)” and cleanse with saline. However, the cleansing agent used was not consistent. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The POC, during the certification period from 5/25/2023 to 7/23/2023, showed SN to perform/teach patient/PCG wound care on right medial dorsal foot by cleansing wound with NS, apply Iodosorb (antibacterial), cover with “Silver Ag” and foam dressing Q day. The SN note dated 5/29/23, showed the patient’s right foot diabetic ulcer was cleansed with sterile normal saline; the interventions included Iodosorb and the dressing was calcium alginate (wound dressing) and foam. On another section of the note showed the right foot wound was cleansed with NS, applied Iodosorb, covered with “Silver Ag” and foam dressing. However, one section of the note showed the use of calcium alginate and another section of the note showed the use of “Silver Ag,” which was inconsistent. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 10's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 5/26/23. The patient was certified for home health services during the certification period from 5/26/23 to 7/24/23. The PT note dated 6/23/23, showed 4/10 (0=no pain and 10=worst pain) “zing” pain on the “right lower leg (near wound).” Further review of the clinical record showed no documented evidence of a wound on the right lower leg. On 7/20/23 at 0946 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 11's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 1/26/23. The patient was certified for home health services during the certification periods from 5/6/23 to 7/4/23 and 7/5/23 to 9/2/23. The SN note dated 6/14/23, showed the patient had a 4/10 (0=no pain and 10=worst pain) headache with congestion pain. Relief measure included rest/Tylenol (analgesic). However, there was no documented evidence Tylenol was included in the POC. On 7/20/23 at 1015 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 12's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 1/27/23. The patient was certified for home health services during the certification period from 5/27/23 to 7/25/23. The ROC/RECERT OASIS dated 5/25/2023, showed recertification verbal order obtained from the physician. Documentation showed the new episode was focused on skilled care/problems: S/P pneumonia and getting IV medications weekly. Documentation showed SN to monitor pain and skin complications. Further review of the clinical record showed no documented evidence the patient was on IV medications weekly. On 7/20/23 at 1049 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the patient was not on IV medications. She was informed and acknowledged the finding. #. Review of Patient 13's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 6/19/22. The patient was certified for home health services during the certification period from 6/19/22 to 8/17/22. The POC, during the certification period from 6/19/22 to 8/17/22, showed vital signs monitoring PRN. The POC showed to assess vital signs and if indicated, pulse oximetry. The POC showed to notify the physician of results out of range: “Diastolic BP 90 mmHg, Systolic BP 160 mmHg, or if patient is symptomatic” The SN note dated 6/30/22, showed the patient’s BP was 152/98 mm Hg. Documentation showed the SN assessed vital signs and notified physician of results out of range: “Diastolic BP 90 mmHg, Systolic BP 160 mmHg, or if patient is symptomatic”. However, there was no documented evidence on the date and time the physician was notified, who was the physician, and what was the physician’s response. On 7/20/23 at 1109 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 14's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 3/6/22. The patient was certified for home health services during the certification periods from 3/6/22 to 5/4/22 and 5/5/2022 to 7/3/2022. The POC, during the certification period from 3/6/22 to 5/4/22, showed SN visits from 3/6/2022 to 3/19/2022, 2 visits every week for 2 weeks for teaching/instruct patient and/or PCG in G-tube care, and how to feed through the g-tube; from 3/6/2022 to 5/4/2022, 1 to 4 visits PRN for G-tube emergency needs; and from 3/20/2022 to 4/30/2022, 1 visit every week for 6 weeks for G-tube care. The POC showed the patient’s medications included metformin (antidiabetic) 850 mg tablet PO BID, glimepiride (antidiabetic) 4 mg tablet PO BID. Lantus Solostar (insulin) 100 u/ml inject 32 units SC BID, vitamin D (supplement) one tablet PO QD, acetaminophen-codeine (opioid analgesic) 300-30 mg per tablet one tablet PO Q six hours PRN, atorvastatin (lipid lowering agent) 20 mg tablet PO QD, ondansetron (antiemetic) 8 mg one tablet PO Q eight hours PRN for nausea, prochlorperazine (antiemetic) 10 mg one tablet PO Q eight hours PRN may use with ondansetron if ondansetron does not control nausea, dexamethasone (corticosteroid) 4 mg tablet PO BID, lorazepam (antianxiety) 1 mg one tablet PO QD PRN for anxiety (one half hour before radiation) for up to 10 doses. a. The SN note date 4/1/22, showed the patient had 4/10 neck pain (0=no pain and 10=worst pain) and relief measures included Percocet (opioid analgesic). * However, there was no documented evidence Percocet was included in the patient’s POC. b. The ROC OASIS dated 4/25/22 and the Recert OASIS dated 5/4/22, showed a section of the note the patient was independent with insulin administration. Another section of the note showed the patient was unable to take injectable medication unless administered by another person, which was not consistent. c. The SN notes showed inconsistency related to wound site. For example: The ROC OASIS dated 4/25/22, showed the patient had a wound on left plantar foot, picture was taken, wound cleansed and dressing changed. On another section of the note showed the patient’s left plantar foot ulcer showed the wound measurement was 1.6 cm (length x 1 cm (width). On another section of the note showed an open wound care problem to the right foot. Documentation showed wound care to consist of cleanse with, aseptic cleanser, apply dry 4 x 4 gauze and Xeroform (wound dressing), secure with paper tape, waterproof tape and Kerlix roll three times a week. * However, documentation showed the wound sites were inconsistent. The Recertification Assessment dated 5/4/22, showed an open wound care problem on the right foot. Documentation showed the intervention included to instruct patient and caregiver in wound care. Documentation showed wound care to consist of cleansing with aseptic cleanser, apply dry 4 x 4 gauze and Xeroform (wound dressing), secure with paper tape, waterproof tape and Kerlix roll three times a week. On another section of the note showed the patient had a left upper plantar foot diabetic ulcer with a measurement of 1.6 cm (length) x 1 cm (width) X 0.2 cm (depth) The POC during the certification periods from 5/5/2022 to 7/3/2022, showed SN wound care each visit on the right foot open wound. The POC included to instruct patient and caregiver in wound care. The POC showed wound care to consist of cleanse with, aseptic cleanser. Apply dry, 4 x 4 gauze and Xeroform, secure with paper tape, waterproof tape and Kerlix roll three times a week. * However, documentation showed two different wound sites in the recertification assessment and one wound site in the POC. On 7/20/23 at 1158 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 17's closed clinical record was initiated on 7/12/23. The clinical record showed the SOC was 2/23/22. The patient was certified for home health services during the certification period from 2/23/22 to 4/23/33. a The SOC OASIS dated 2/23/22, on the narrative section of the note showed the patient was admitted for a diagnosis of Stage 2 sacral pressure injury. The “LDA” and Wound Assessment part of the form showed the patient had a midline gluteal and right medial buttock denuded moisture damage wound. Documentation showed the length and width of the midline gluteal and right medial buttock denuded moisture damage wound. However, there was no documented of a wound measurement/assessment of the sacral pressure injury. There was no documented evidence if the midline gluteal cleft and right medial buttock denuded moisture damage wound was the Stage 2 sacral pressure injury. a. The POC, during the certification period from 2/23/22 to 4/23/33, showed the following information: - Wound care PRN to gluteal cleft and right buttocks. Cleanse with wound cleanser, apply Medihoney (wound dressing), cover with foam dressing, two times per week The physician’s order dated 3/9/22, showed cleanse gluteal cleft and right buttocks “MSRD” with wound cleanser, apply Medihoney, cover with “coccyx mepilex dressing” two times per week . The SN note dated 3/23/22, showed the following information: -under the “LDA” and Wound Assessment section, the gluteal and right buttock wound was cleansed with wound cleanser and was open to air. Documentation showed the gluteal and right buttock wound had a barrier ointment applied to the peri wound. -under wound management problem, wound care was performed on the gluteal and right buttock by cleansing with wound cleanser, patted dry, applied Medihoney (wound dressing) and covered with sacral foam border dressing. * However, the treatment performed to the gluteal cleft and right buttock were not consistent. Review of the agency's P&P titled Ongoing Assessments dated 9/2021 showed during each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) including blood pressure, pulse, pulse oximetry, respirations, temperature; bowel sounds; and elimination (urinary ad bowel). Review of the agency's P&P titled Pain Assessment/Management dated 11/2022 showed all patients will receive an initial and ongoing pain assessments by qualified disciplines. When pain is identified, a more comprehensive pain assessment will be completed and documented. Pain assessments will be appropriate to the patient's age, condition, ability to understand, and if the pain is acute or chronic. Pain assessments will be documented to facilitate regular reassessment and follow-up by clinicians. 1a. Review of Patient 1's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/9/23. The patient was certified for home health services during the certification periods from 4/10/23 to 6/8/23 and 6/9/23 to 8/7/23. Review of the SN Visit notes during the certification period, showed there were multiple dates where the SN did not document the patient’s last bowel movement. For example, review of the SN Repeat Visit note dated 4/12/23, showed the SN assessed the patient’s GI system to be within defined limits. However, there was no documented evidence showing the patient’s last bowel movement. b. Review of the OT and PT Visit notes during the certification period, showed there were multiple dates where the OT and/or PT did not document the patient’s complete vital signs. For example, review of the OT Repeat Visit note dated 6/26/23, showed the OT only documented the patient’s blood pressure, respiratory rate, and heart rate. There was no documented evidence showing the patient’s temperature. On 7/20/23 at 0834 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed of the findings. The QM Nurse verified the patient’s complete vital signs and last bowel movement should be assessed and documented every visit. 2a. Review of Patient 4's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 4/25/23. The patient was certified for home health services during the certification periods from 4/25/23 to 6/23/23 and 6/24/23 to 8/22/23. The POC, for both certification periods, showed to monitor and address pain. Review of the PT Visit notes during the certification period, showed there were multiple dates where the PT did not accurately and completely assess the patient’s pain. For example, on 4/27/23, the PT assessed the patient to have an achy and throbbing pain on the right lower leg extremity. However, there was no documented evidence of the numerical pain scale. On 7/4/23, the PT documented the patient had a 0/10 pain. However, the PT also documented under the Pain Assessment in Advanced Dementia Scale and assessed the patient to have a score of 2. Further review of the clinical record showed no documented evidence the patient had a dementia diagnosis. b. Review of the SN Repeat Visit note dated 7/6/23, showed the SN performed dressing changes to the left and right legs. However, there was no documented evidence showing the patient had a wound on the left leg or had a dressing change order for it. c. Review of the SN and PT Visit notes during the certification period from 4/25/23 to 6/23/23, showed there were multiple dates where the SN and/or PT did not completely assess the patient’s last bowel movement and vital signs. For example, review of the SN Repeat Visit note dated 6/8/23, showed the SN assessed the patient’s GI system to be within defined limits. However, there was no documented evidence showing the patient’s last bowel movement. Review of the PT Repeat Visit note dated 6/12/23, showed the PT only documented the patient’s blood pressure, respiratory rate, oxygen saturation, and heart rate. There was no documented evidence showing the patient’s temperature. On 7/20/23 at 0920 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the findings. 3. Review of Patient 16's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification period from 12/22/22 to 2/19/23. Review of the SN Visit notes during the certification period, showed there were multiple dates where the SN did not document the patient’s last bowel movement. For example, review of the SN Repeat Visit note dated 1/1/23, showed the SN assessed the patient’s GI system. However, there was no documented evidence showing the patient’s last bowel movement. On 7/20/23 at 1100 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the responsibility for the day-to-day operations by not implementing the agency's P&P as evidenced by: * The agency failed to ensure the written agreements for 11 of the 11 contractors (Contractors 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) included the required elements in the contracts as per Title 22. * The agency failed to ensure the wounds were measured at least weekly as per the agency's P&P for three of 18 sampled patients (6, 9, and 17). * The agency failed to ensure the P&P for PICC line removal and infusion access device was implemented for one of 18 sampled patients (Patient 11). These failures had the potential to negatively impact the agency’s operational performance. 2. The agency’s P&P titled Wound Standards revised date 9/20, showed wound will be measured at least weekly with the frequency increasing at the discretion of the direct care nurse. a. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. The ROC OASIS dated 6/11/23, showed the patient had one observable surgical wound. Documentation showed the patient resumed to home health care following a hospitalization for possible heart surgery per patient. Documentation showed the patient presented with mobility issues: unsteady gait due to open wound of foot, wounds/skin/incisions of the right foot with wound vacuum. Review of the SN notes showed visits were conducted during Week 5 (6/11/23 to 6/17/23). However, there was no documented evidence of right foot diabetic ulcer’s measurement during Week 5. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. b. Review of Patient 9's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 2/10/20. The patient was certified for home health services during the certification periods from 3/26/2023 to 5/24/2023 and 5/25/2023 to 7/23/2023. The Recert OASIS dated 3/4/23, showed the patient had a right foot diabetic ulcer. The SN notes showed on Week 2 (4/2/23 to 4/8/23) and Week 3 (4/9/23 to 4/15/23), the patient’s right foot diabetic ulcer had a measurement of 1.5 cm (length) X 0.3 cm (width). However, there was no documented evidence of the depth of the patient’s right foot diabetic ulcer. The SN note showed the SN conducted visits during Week 5 (4/23/23 to 4/29/23) and Week 6 (4/30/23 to 5/6/23). However, there was no documented evidence of the wound measurement of patient’s right foot diabetic ulcer. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 17's closed clinical record was initiated on 7/12/23. The clinical record showed the SOC was 2/23/22. The patient was certified for home health services during the certification period from 2/23/22 to 4/23/33. The SOC OASIS dated 2/23/22, showed the patient had a skin tear left lower arm had a right medial buttock denuded moisture damage wound . Review of the SN notes dated 3/4/22, showed a visit was conducted during Week 2 (2/27/22 to 3/5/22). Documentation showed the patient had a skin tear on the left lower arm with a measurement of 5 cm (length) x 1.5 cm (width). The patient also had a right medial buttock denuded moisture damage wound with a measurement of 3 cm (length) x 1.5 cm (width). However, there was no documented evidence of the wound depth on the left lower arm skin tear and right medial buttock denuded moisture damage wound during Week 2. On 7/20/23 at 1149 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 3. The agency’s P&P titled Adult Access Device Maintenance and Infusion Therapy Guidelines Grid dated 10/19, showed the following information: -For implanted ports the discard amount for blood draw is 5 ml and the flush amount after blood draws is 20 ml NS followed by heparin, if applicable. The final lock solution for heparin is 5 ml 100 u/ml. -For PICC lines (non-valved and valved catheter) the discard amount for blood draw is 5 ml. The flush amount after blood draw for non-valved catheter is 20 ml NS followed by heparin, if applicable; and the final lock solution for heparin is 3 ml 10 u/ml. The flush amount after blood draw for valved catheter is 20 ml NS and there is no final lock solution with heparin. The agency’s P&P titled “Peripherally inserted central catheter (PICC) removal, home care” dated 08/22, showed after successful catheter removal, apply manual pressure to the site with a sterile gauze the hemostasis had been achieved. Cover the site with a petroleum-based ointment and a sterile occlusive gauze dressing or transparent permeable dressing to seal the skin to vein tract and reduce the risk of retrograde embolus. Label the dressing with the date applies or date to be changes as directed by the agency. Assess the integrity of the removed catheter to ensure that it is intact and measure its length. Compare the catheter length with the original insertion length to ensure the entire catheter was removed. Review of Patient 11's clinical record was initiated on 7/17/23. The clinical record showed the SOC was 1/26/23. The patient was certified for home health services during the certification periods from 5/6/23 to 7/4/22 and 7/5/23 to 9/2/23. The Recert OASIS dated 5/1/23, showed port-a-cath was accessed; flushed with 10ml NS; aspirated 10ml of blood, discarded; and aspirated 10ml blood for CBC, CMP, and blood cultures. Documentation showed blood draw and flush was performed. Documentation showed the saline amount was 20 ml, the heparin concentration was 50 u/ml; and the amount of heparin was 5 ml. * However, 10ml of blood was discarded instead of five ml; and the heparin concentration was 50 u/ml instead of 100 u/ml as per the agency’s P&P. The SN note dated 5/15/23, showed the patient’s port -a- cath had been removed with Steri-Strips (skin closures) to site. Documentation showed the SN flushed PICC lumen w/ 10ml NS; aspirated 10ml of blood and discarded; aspirated 10ml of blood for labs; and flushed w/ 10ml NS. * However, 10ml of blood was discarded instead of five ml; and was flushed with 10 ml NS instead of 20 ml as per the agency’s P&P. The SN note dated 5/22/23, showed the SN flushed the PICC port with 10ml NS; aspirated 10ml of blood, discarded; and aspirated 10ml blood for labs; and flushed with 20 ml NS. * However, 10ml of blood was discarded instead of five ml as per the agency’s P&P. The SN note dated 5/24/23, showed SN removed PICC without difficulty, 4x4 gauze applied, secured with tape. Documentation showed the patient tolerated the procedure. * However, there was no documented evidence the PICC line catheter was measured after the PICC line catheter was removed. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. Review of the agency's P&P titled Responsibilities/Supervision of Clinical Services dated 9/2021 showed the Clinical Director will oversee the day-to-day clinical operations. 1. According to Title 22 Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the following: the rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; the role, if any, of the agency and the contracted individual or agency in the patient admission process, patient assessment, the development, review, and revision of the plan of treatment or plan of care, patient care conferences, the scheduling of visits or hours, discharge planning, the submission to the agency of documentation of services provided; and that agreements shall be reviewed and revised as necessary. Review of the written agreements between the agency and Contractors 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 providing supplemental staffing and shared resources was initiated on 7/18/23. The written agreements did not include the rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; the role, if any, of the agency and the contracted individual or agency in the patient admission process, patient assessment, the development, review, and revision of the plan of treatment or plan of care, patient care conferences, the scheduling of visits or hours, discharge planning, the submission to the agency of documentation of services provided; and that agreements shall be reviewed and revised as necessary. On 7/20/23 at 1145 hours, an interview and concurrent record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge and transfer summaries were completed and sent to the physician timely for three of the 18 sampled patients (Patients 6, 12, and15). This failure created the risk of providing substandard care to these patients. #. Review of Patient 6's clinical record was initiated on 7/10/23. The clinical record showed the SOC was 5/14/23. The patient was certified for home health services during the certification period from 5/14/23 to 7/12/23. The SN Missed Visit Note dated 6/26/23, showed the nursing service was cancelled because the patient was admitted to GACH. The Transfer Without Discharge OASIS dated 6/26/23, showed the patient was admitted to a GACH due to a ruptured appendicitis. Review of the HHA’s document showed the transfer summary was sent on 6/30/23, which was more than two business days of becoming aware of an unplanned transfer. On 7/20/23 at 0856 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. On 7/20/23 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. #. Review of Patient 12's clinical record was initiated on 7/13/23. The clinical record showed the SOC was 1/27/23. The patient was certified for home health services during the certification period from 5/27/23 to 7/25/23. The Transfer Without Discharge OASIS dated 6/18/2023, showed the patient was admitted to GACH on 06/18/23 due to low platelets. Review of the HHA’s document showed the transfer summary was sent on 6/22/23, which was more than two business days of becoming aware of an unplanned transfer. On 7/20/23 at 1049 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the patient was not on IV medications. She was informed and acknowledged the finding 1. Review of Patient 15's closed clinical record was initiated on 7/11/23. The clinical record showed the SOC was 9/13/22. The patient was certified for home health services during the certification periods from 9/13/22 to 11/11/22 and 11/12/22 to 12/10/22. The patient was discharged on 12/14/22. Review of the document provided by the agency titled Home Health Patient Discharge and Transfer Summary Timeline Report, showed Patient 15’s discharge summary was sent late on 1/11/23. On 7/20/23 at 1045 hours, an interview and concurrent clinical record review was conducted with the QM Nurse. The QM Nurse was informed and acknowledged the finding.