Every finding on record at Dominion Home Health Care, Inc

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on a review of the Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the risk assessment was reviewed and updated. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 11/15/22 at 9:40 AM. The Plan contained the document titled: “2018 Hazard Vulnerability Analysis". The Plan lacked any other risk assessments. As of 11/15/22, the Plan lacked documentation that the risk assessment was reviewed and updated since 2018. 2. During an interview with the Administrator and Director of Nursing on 11/16/22 at 10:50 AM, the Administrator was unable to provide documentation that the Agency had reviewed and updated the risk assessment since 2018. During the same interview, the Administrator confirmed the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Communication Plan contained the required components. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 11/15/22 at 9:40 AM. The Plan contained the document titled: "Agency Emergency Contact List" which lacked the names and contact information of the direct staff, contracted staff/contracted agencies and patient's physicians. 2. During an interview with the Administrator and Director of Nursing on 11/16/22 at 10:15 AM, the Administrator was unable to provide documentation that the communication plan included the names and contact information of the direct staff, contracted staff/contracted agencies and patient's physicians. During the same interview the Administrator confirmed the above findings.

Survey Team arrived on 11/7/22 at 9:01 AM to conduct a recertification survey. Name of the Agency and the business hours of Monday to Friday from 9:00 AM to 5:00 PM were displayed on the front door. The front door was closed and locked; survey team was not able to enter the office. The front windows had vertical blinds that blocked off access of the view of the office space inside. Called the number listed on the directory/office window but the call was directed to voicemail. Left a message to call IDPH number back but did not receive a response. At 9:20 AM, called IDPH Supervisor to inform that the Agency office was closed and was unable to contact any Agency Staff. Revisited Agency office at 10:00 AM but the door was still locked. At 10:12 AM, IDPH Supervisor called and stated that there was no response from the Agency. Survey Team left at 10:30 AM. Recertification survey completed 11/17/22. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients POC/PsOC = Plan of Care/Plans of Care SOC = Start of Care RN = Registered Nurse SN = Skilled Nurse AM = Morning PM = Afternoon, Evening ml = milliliters MCG = micrograms IU = International Units KCL = Potassium Chloride MEQ = Milliequivalents MG = milligrams COVID-19 = Coronavirus 2019 CMS = Centers for Medicare and Medicaid NOMNC = Notice of Medicare Non-Coverage ABN = Advance Beneficiary Notice of Non-Coverage HHCCN = Home Health Change of Care Notice

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure initial comprehensive assessments were performed by the RN within 48 hours of Physician referral for home health agency services. This was found in 5 of 8 Pts. (Pts. #6, 8, 2, 3, and 4) clinical records reviewed. Findings include: 1. Pt. #6. SOC 12/2/21. Primary Diagnosis: Obesity, Unspecified. The clinical record was reviewed on 11/15/22 at 11:15 AM. The record included progress notes from a Nursing Home, dated 11/23/21, which indicated “return home.” The record lacked Physician orders for referral, or a specific start of care date for home health agency services. The record also contained the initial comprehensive assessment, completed by the RN on 12/2/21, 9 days after the patient’s discharge from the Nursing home. 2. Pt. #8. SOC 6/29/22. Diagnoses include: Neuromuscular Dysfunction and Paraplegia. The clinical record was reviewed on 11/15/22 at 2:10 PM. The record contained the Physician’s referral for home health services dated 6/24/22. The record also included the start of care initial assessment, completed by the RN on 6/29/22, five days after the Physician’s referral. 3. Pt. #2. SOC 9/29/22. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/14/22 at 2:00 PM. The record contained the form titled, "Documentation of Face-to-Face Encounter" signed by the Physician on 9/9/22 and faxed to the Agency on 9/14/22. The record lacked documentation that the Pt. was discharged from an inpatient facility, or the Physician ordered a specific SOC date. The SOC comprehensive assessment was conducted by the SN on 9/29/22 (15 days after the Agency received the referral). As of 11/14/22, the record lacked documentation that the Agency initiated service within 48 hours of the referral date. 4. Pt. #3. SOC 5/21/22. Diagnoses: Type 2 Diabetes Mellitus, Uncomplicated Unspecified Asthma and Essential (Primary Hypertension). The clinical record was reviewed on 11/14/22 at 3:00 PM. The record contained form titled, "Documentation of Face-to-Face Encounter" signed by the Physician on 5/13/22 and faxed to the Agency on 5/18/22. The record lacked documentation that the Pt. was discharged from an inpatient facility, or the Physician ordered a specific SOC date. The SOC comprehensive assessment was conducted by the SN on 5/21/22 (3 days after the Agency received the referral). As of 11/14/22, the record lacked documentation that the Agency initiated service within 48 hours of the referral date. 5. Pt. #4. SOC 4/14/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/15/22 at 9:10 AM. The record contained the referral for an inpatient facility that included "...Outpatient referral...for admission...Disciplines requested: Nursing and Physical Therapy". This referral was faxed to the Agency on 4/10/22. The SOC comprehensive assessment was conducted by the SN on 4/14/22 (4 days after the Agency received the referral), included the "Inpatient Discharge Date 04/10/2022", and lacked a Physician ordered SOC date. As of 11/15/22, the record lacked documentation that the Agency initiated service within 48 hours of the patient's inpatient discharge date. 6. During an interview with the Administrator and Director of Nursing on 11/16/22 from 10:35 AM to 12:30 PM, the Director of Nursing confirmed the initial assessment visits were conducted after 48 hours of the referral date and inpatient discharge date.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observation and interview during home visits, Agency policy review and staff interviews, it was determined the Agency failed to ensure the POC contained current medications and treatments. This was found in 3 of 8 (Pts. 2, 3 and 8) clinical records reviewed. Findings include: 1. Pt. #2. SOC 9/29/22. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/14/22 at 2:00 PM. The record contained the POC effective 9/29/22 requiring the Pt. to take the medications: "Metformin 500 MG Take 1 Tablet by Mouth Daily, Bred-Ellipta 2 Puffs by Mouth Daily, Pantoprazole 40 MG Take 1 Tablet by Mouth Daily". A home visit was conducted on 11/15/22 at 11:45 AM with the Director of Nursing. During the home visit, the medications were observed, and interviews were conducted with the caregiver (who gives the Pt. her medications) and the Director of Nursing. The caregiver stated, that since the Pt. was admitted to the Agency (on 9/29/22), the Pt. does not take Metformin, Bred-Ellipta and Pantoprazole. The Director of Nursing stated, the medications were included on the Physician's Face to Face Encounter form, and she was aware the Pt. does not take these medications. These medications were observed, and the caregiver stated the medications were taken for more than a year, the medications were not included in the POC effective 9/29/22: Vitamin E 450 MG 1 softgel by mouth daily, women's multivitamin 1 tablet by mouth daily, Vitamin B12 1000 MCG 1 capsule by mouth daily and Vitamin C 1000 MG 1 tablet by mouth daily. The Director of Nursing failed to contact the Physician to notify him of a discrepancy with the medications. As of 11/14/22, the POC effective 9/29/22 was inaccurate. 2. Pt. #3. SOC 5/21/22. Diagnoses: Type 2 Diabetes Mellitus, Uncomplicated Unspecified Asthma and Essential (Primary Hypertension). The clinical record was reviewed on 11/14/22 at 3:00 PM. The record contained PsOC for the certification periods of 5/21/22 to 7/19/22, 7/20/22 to 9/17/22 and 9/18/22 to 11/16/22. The record contained the POC effective 5/21/22 requiring the Pt. to take the medications: "Ferrous Sulfate Take 1 Tablet by Mouth Daily, Vitamin D3 2000 IU Take 1 Tablet Daily". The PsOC effective 7/20/22 and 9/18/22 required the Pt. to take the medications: Potassium (KCL) 10 MEQ Daily by Mouth, Ferrous Sulfate Take 1 Tablet by Mouth Daily, Vitamin D3 2000 IU Take 1 Tablet Daily". A home visit was conducted on 11/15/22 at 12:25 PM with the Director of Nursing. During the home visit, the medications were observed, and interviews were conducted with the caregiver who gives the Pt. her medications. The caregiver stated the Potassium, Ferrous Sulfate, Vitamin D3 were discontinued "more than a year ago". The Director of Nursing stated, the medications were included on the Physician's Face to Face Encounter form, and she was aware the Pt. does not take these medications. The Director of Nursing failed to contact the Physician to notify him of a discrepancy with the medications. As of 11/14/22, the PsOC were inaccurate. 3. Pt. #8. SOC 6/29/22. Diagnoses include: Neuromuscular Dysfunction and Paraplegia. The clinical record was reviewed on 11/15/22 at 2:10 PM. The record contained the SOC initial comprehensive assessment dated 6/29/22, which indicated Pt. #8 had a supra pubic indwelling urinary catheter, 16 French, inflated with a 30 ml balloon. The pt. also had a urostomy tube/urethral stent, with directions: “flush with 10 ml of saline twice daily, ostomy care by SN weekly.” The POC effective 6/29/22 to 8/27/22 lacks Physician’s orders for the assessment and care of Pt. #8’s supra pubic urinary catheter or urostomy tube/urethral stent. The record also included the comprehensive recertification assessment dated 8/24/22, which indicated the on-going presence of the Patient’s indwelling supra pubic urinary catheter, along with the directions “frequency of change: by SN during visits twice monthly and as needed.” This assessment also included documentation of Pt. #8’s urostomy tube/urethral stent, along with the directions: “flush with 10 ml of saline twice daily.” The POC effective 8/28/22 to 10/26/22 lacks Physician’s orders for the assessment and care of Pt. #8’s supra pubic urinary catheter or urostomy tube/urethral stent. The record also contained the comprehensive recertification assessment dated 10/26/22, which indicated the on-going presence of the Patient’s indwelling supra pubic urinary catheter, along with the directions: “frequency of change: bi-weekly and as needed.” This assessment also included documentation of Pt. #8’s urostomy tube/urethral stent, with the directions: “Irrigate the suprapubic catheter and the urostomy tube with 10 ml of normal saline three times daily.” The POC effective 10/27/22 lacks Physician’s orders for the assessment and care of Pt. #8’s supra pubic urinary catheter or urostomy tube/urethral stent. 4. During interviews with the Administrator and the Director of Nursing on 11/16/22 from 10:35 AM to 12:30 PM, the above findings were confirmed. The Director of Nursing stated all Pt. medications and treatments should be documented on the POC.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on a review of personnel file review and staff interview, it was determined the Agency failed to develop and implement a policy regarding employee COVID-19 vaccinations, including criteria for the evaluation and acceptance of employee requests for exemption from the COVID-19 vaccination, as well as the mitigations to be put in place to protect its Pts. from the spread of COVID-19 from un-vaccinated staff members. This was found in 1 of 4 (Employee #2) employees reviewed for compliance with COVID-19 vaccinations, and has the potential to affect all pts. who receive services from the Agency. Findings include: 1. The personnel file of Employee #2 was reviewed on 11/15/22 at 2:30 PM. The file contained an undated summary written by Employee #2, which indicated Employee #2 declined to receive the COVID-19 vaccination due to religious reasons. There was no documentation that Employee #2’s declination was evaluated or accepted by the Agency. The file also included a document titled “Unvaccinated Staff Records,” which indicated Employee #2 performed COVID-19 self-testing weekly from January 1, 2022 to February 19, 2022, but lacked documentation of COVID-19 self-testing thereafter. 2. The Agency’s policy regarding COVID-19 vaccinations for staff providing direct Pt. care was requested on 11/14/22 at 10:30 AM and 3:45 PM, as well as on 11/15/22 at 11:50 AM and 2:30 PM, yet was never received. On 11/15/22 at 2:30 PM, the Administrator stated the Agency did not have such a policy. 3. During an interview with the Administrator and Director of Nursing on 11/16/22 at 11:45 AM, the above findings were confirmed.

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: A. Based on a review of the Agency's Pt. admission folder, observation during home visits, and staff interview, it was determined the Administrator failed to ensure accurate information pertaining to the Agency's location was presented to Pts./patient's representative. This has the ability to affect all services provided by the Agency. Findings include: 1. The Pt. admission folder was reviewed on 11/14/22 at 11:45 AM, it contained the "Patient Information Book" and the Agency's brochure. Both contained an inaccurate address for the Agency. 2. The following home visits were conducted on 11/16/22 from 11:45 AM to 1:00 PM with the Director of Nursing: Pt. #2. SOC 9/29/22. Pt. #3. SOC 5/21/22. During the home visits, the Pt. admission folder was observed, it contained the "Patient Information Book" and the Agency's brochure. Both contained an inaccurate address for the Agency. 3. During the entrance interview with the Administrator and Director of Nursing on 11/14/22 at 10:23 AM, the Administrator stated the Agency had relocated in May or July 2021, from its previous location to the current location. 4. During an interview with the Administrator and Director of Nursing on 11/16/22 at 10:35 AM, the Administrator confirmed the Agency had relocated more than a year ago and failed to update the Pt. admission folder, and Agency brochure with the Agency's current/accurate address.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interviews, it was determined the Agency failed to ensure that documentation entered into the clinical record was appropriate and/or contained the required information. This was found in 8 of 8 (Pts. # 2, 3, 4, 1, 5, 6, 7 and 8) clinical records reviewed. Findings include: 1. Pt. #2. SOC 9/29/22. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/14/22 at 2:00 PM. The record contained the form titled, "Home Health Change of Care Notice (HHCCN) was dated 9/23/22 and signed by the Pt./patient's representative. The CMS form required the SN to document the items/services to change, effective date of the change and the reason for giving the Pt. the form to review and sign. The form was left blank, it lacked the required information indicated above as required by CMS. The record included the form titled, "Advance Beneficiary Notice of Noncoverage (ABN) signed by the Pt./patient's representative and dated 9/23/22. The CMS form required the SN to document the care/service that Medicare does not pay, reason Medicare may not pay, estimated cost, and 1 of 3 options the pt./patient's representative may choose regarding payment of the care/service that may not covered by Medicare. The form was left blank, it lacked the the required information indicated above as required by CMS. The record included the last page of the form titled, "NOMNC" signed by the Pt./patient's representative and dated 9/23/22. The CMS form required the SN to document care not covered by Medicare and provide this notice within 2 days calendar prior to the service end date. The form was left blank, it lacked the required information indicated above as required by CMS. 2. Pt. #3. SOC 5/21/22. Diagnoses: Type 2 Diabetes Mellitus, Uncomplicated Unspecified Asthma and Essential (Primary Hypertension). The clinical record was reviewed on 11/14/22 at 3:00 PM. The record contained the form titled, "Home Health Change of Care Notice (HHCCN) was dated 5/21/22 and signed by the Pt. The CMS form was left blank, it lacked the required information. The record included the form titled, "Advance Beneficiary Notice of Noncoverage (ABN) signed by the Pt./patient's representative and dated 5/21/22. The CMS form was left blank, it lacked the the required information. The record included the last page of the form titled, "NOMNC" signed by the Pt./patient's representative and dated 5/21/22. The CMS form was left blank, it lacked the required information. 3. Pt. #4. SOC 4/14/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/15/22 at 9:10 AM. The record contained the form titled, "Home Health Change of Care Notice (HHCCN) dated 4/13/22 and signed by the Pt./patient's representative. The CMS form was left blank, it lacked the required information. The record included the form titled, "Advance Beneficiary Notice of Noncoverage (ABN) signed by the Pt. and dated 4/13/22. The CMS form was left blank, it lacked the required information. The record included the last page of the form titled, "NOMNC" signed by the Pt. and dated 4/13/22. The CMS form was left blank, it lacked the required information. The Agency's SN visit note required the SN to document the patient's intensity of pain using a pain scale (Pain scale intensity rating: 0 equal no pain to 10 equal severe pain), as required by the SN visit note and Agency policy. The SN visit notes dated 10/11/22, 10/18/22, 10/25/22 and 11/1/22 contained documentation that the Pt. experienced "sternal aching" pain. The SN visit notes indicated above lacked a pain scale intensity rating. 4. Pt. #1. SOC 10/10/22. Primary Diagnosis: Multiple Sclerosis. The clinical record was reviewed on 11/14/22 at 1:30 PM. The record contained a document titled “Notice of Medicare Non-Coverage,” which was signed by the pt. on 10/10/22. The sections indicating what type of current services would be ending, and when the effective date Medicare coverage would end were left blank. 5. Pt. #5. SOC 6/3/22. Primary Diagnosis: Unspecified Dementia. The clinical record was reviewed on 11/15/22 at 10:00 AM. The record included the last page only of a “NOMNC” document, signed by the pt. on 6/3/22. The document lacked information on what type of current services would be ending, and when the effective date Medicare coverage would end. The record also contained a form titled “Advance Beneficiary Notice of Non-Coverage (ABN), which was signed by the pt. on 6/3/22. The sections listing what services/items Medicare may not pay for, along with the reason Medicare may not pay, the estimated cost to the pt., and the option to agree or not to agree to those services/items were all left blank. The record also included a document titled “Home Health Change of Care Notice (HHCCN),” which was signed by the pt. on 6/3/22. The sections listing what date home health services would change, the items/services that would change with the reason why, and the patient’s decision to accept the changes or look for another agency, were all left blank. 6. Pt. #6. SOC 12/2/21. Primary Diagnosis: Obesity, Unspecified. The clinical record was reviewed on 11/15/22 at 11:15 AM. The record contained a document titled “Notice of Medicare Non-Coverage,” which was signed by the pt. on 12/2/21. The sections indicating what type of current services would be ending, and when the effective date Medicare coverage would end were left blank. The record also contained a form titled “Advance Beneficiary Notice of Non-Coverage (ABN), which was signed by the pt. on 12/2/21. The sections listing what services/items Medicare may not pay for, along with the reason Medicare may not pay, the estimated cost to the pt., and the option to agree or not to agree to those services/items were all left blank. The record also included a document titled “Home Health Change of Care Notice (HHCCN),” which was signed by the pt. on 12/2/21. The sections listing what date home health services would change, the items/services that would change with the reason why, and the patient’s decision to accept the changes or look for another agency, were all left blank. 7. Pt. #7. SOC 5/13/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/15/22 at 12:30 PM. The record included the last page only of a “NOMNC” document, signed by the pt. on 5/13/22. The document lacked information on what type of current services would be ending, and when the effective date Medicare coverage would end. The record also contained a form titled “Advance Beneficiary Notice of Non-Coverage (ABN), which was signed by the pt. on 5/13/22. The sections listing what services/items Medicare may not pay for, along with the reason Medicare may not pay, the estimated cost to the pt., and the option to agree or not to agree to those services/items were all left blank. The record also included a document titled “Home Health Change of Care Notice (HHCCN),” which was signed by the pt. on 5/13/22. The sections listing what date home health services would change, the items/services that would change with the reason why, and the patient’s decision to accept the changes or look for another agency, were all left blank. 8. Pt. #8. SOC 6/29/22. Diagnoses include: Neuromuscular Dysfunction and Paraplegia. The clinical record was reviewed on 11/15/22 at 2:10 PM. The record contained a form titled “Advance Beneficiary Notice of Non-Coverage (ABN), which was signed by the pt. on 6/29/22. The sections listing what services/items Medicare may not pay for, along with the reason Medicare may not pay, the estimated cost to the pt., and the option to agree or not to agree to those services/items were all left blank. The record also included a document titled “Home Health Change of Care Notice (HHCCN),” which was signed by the pt. on 6/29/22. The sections listing what date home health services would change, the items/services that would change with the reason why, and the patient’s decision to accept the changes or look for another agency, were all left blank. 9. The Agency policy titled “Medical Record Entries and Authentication” was reviewed on 11/16/22 at 10:00 AM. The policy required: “…All entries in patient records will be legible, clear, complete…” 10. The Agency policy titled “Pain Assessment and Reassessment” was reviewed on 11/16/22 at 10:15 AM. The policy required: “…1. Each patient receiving skilled nursing services will have pain assessed initially and on an ongoing basis using established criteria, which may include: Intensity (using pain rating scale)…” 11. During interviews with the Administrator and Director of Nursing on 11/16/22 from 10:35 AM to 12:30 PM, it was confirmed the documents listed above were incomplete. The Director of Nursing stated all documents and forms must be completely filled out.