Every finding on record at Emerald Home Health, Inc

The following reflects the findings of the California Department of Public Health, Licensing and Certification, during a Federal Recertification Survey conducted from 7/8/24 through 7/10/24. Representing the Department: Surveyor ID #43745, HFEN Surveyor ID#39912, HFEN The agency census was 40. The patient sample was 7.

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 record review and interview, the home health agency failed to ensure advanced directive information was included in the plans of care of all its active patients. This failure had the potential to result in the delay of necessary treatment compatible with the legally recognized medical decision maker’s wishes during an emergency situation. Findings: During a review of the agency’s policy and procedures (P&P), titled, “Advanced Directive,” undated, the P&P indicated in part, “Documentation... The Registered Nurse/Therapist shall document on the Assessment Form if the client has executed an advanced directive, and if so, what type. There must also be documentation that the client received written information about advanced directives and the agency’s policy for responding to client requests... The attending physician/allowed non-physician practitioner (NPP) shall be notified of all advanced directives, including both written and oral statements by the client. This notification shall be documented in the client’s chart....” During an interview on 7/10/24 at 1:20 p.m., with the agency’s Administrator (ADM), ADM verbalized that patients were given advanced directive information upon admission and if a patient did not complete one, it was assumed that the patient was a full code (providing life-saving measures if the patient’s heart or breathing stops). ADM also verbalized that not all of the agency’s active patients have a code status reflected in their plans of care.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency failed to update the medication list for one of seven sampled patients (Patient 4). This facility failure had the potential to result in ineffective drug therapy and adverse effects. During a home visit with the physical therapist (PT) on 7/9/24 at 10:59 am, home packet was reviewed. The medication reconciliation list dated 6/28/24 does not match the actual medication the patient was currently taking. Carvedopa – Levadopa (used to treat Parkinson’s disease) has a different dose listed. Midorine (used to treat low blood pressure) has different dose listed. Metolazone (used to reduce amount of water in the body) was missing from the medication reconciliation list and Donepezil (used to improve mental function) was missing from the medication reconciliation list. During an interview with the patient’s wife on 7/9/24 at 11:15 am, the wife indicated the last time the registered nurse (RN) visited was on 7/5/24. During that visit the wife of the patient indicated she provided the list of his current medication. The wife provided the list of current medication dated 7/3/24. During an interview with the director of patient care service (DPCS) on 7/9/24 at 12:46 am, the DPCS indicated when the RN reconciles the medication every visit. If there is a change, the RN will update the reconciliation list and leave a copy for the patient. The DPCS acknowledged this was not done with Patient 4’s medication reconciliation list. The facility’s policy and procedure titled “Medication Reconciliation”, no date indicates “Medications will be reviewed with the client on each home visit to determine if other prescriptions or non-prescription drugs are being taken.”

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure its management and operation were effective and operating within all legal bounds when: 1. The agency furnished dietary/nutrition counseling services not included in its current, State- licensed approved home health services. 2. The agency’s governing body (GB) failed to regularly meet to evaluate the agency's performance and review areas needing improvement. These failures had the potential to result in the provision of ineffective care and services to patients. Findings: 1. During the entrance conference interview with the agency’s Administrator (ADM) on 7/8/24 at 11 a.m., ADM verbalized that aside from skilled nursing, home health aide, physical therapy, occupational therapy, speech therapy and medical social services, the agency also provided dietary/nutrition counseling to patients. During a review of the agency’s, “CMS (Centers for Medicare & Medicaid Services) Form 1572(a),” dated 7/8/24, completed by ADM, Section 18 (Services Offered) of the form indicated a check mark under “08 = Nutritional Guidance.” During a review of the agency’s current State license, expiring 1/14/25, the license failed to indicate that the agency was approved for dietary/nutrition counseling services. During a review of the agency’s business brochure, the brochure failed to indicate that dietary/nutrition counseling was included in the services the agency offered. During an interview on 7/8/24 at 11:30 a.m., with ADM, ADM was informed that dietary/ nutrition counseling services was not included in agency’s brochure and was not an approved service under its current State license. ADM verbalized that the service was not regularly offered. ADM was made aware that the addition or deletion of any home health service needs to be approved by the State. 2. During a concurrent interview and review of the agency’s “GB Meeting Minutes,” on 7/10/24 at 1:50 p.m., with ADM, ADM verbalized that the agency’s GB did not have regularly scheduled meetings. The last GB meeting was conducted in July of 2020 as indicated in the minutes.

The following reflects the findings of the California Department of Public Health, Licensing and Certification during a Recertification Survey. One COP not met (CFR 484.70 - G 687). Representing the Department: 33720 HFEN 40799-HFEN 39814-HFEN Census: 30 Sample size: 7 Home visits: 3

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 facility failed to ensure three of seven sampled patients (Patient 7, 5, and 1), Plan of Care ((POC) an individualized written plan that specifies the care and services necessary to meet the patient’s needs and goals) were accurate and complete. For Patient 7, 5, and 1, these facility failures had the potential to result in unmet medical needs and goals. During a concurrent interview and record review on 4/6/22, starting at 1:50 p.m., with director of patient care services (DPCS) , Patient 1's closed medical record revealed Patient 1's most recent certification period documented on the plan of care was from 12/23/21--2/20/22, Further review of closed record revealed Patient 1 was discharged on 12/31/21, DPCS indicated Patient 1 moved out of the area and expired on 1/31/22. Record revealed the following: 1. On 12/18/21- Physician telephone order to recertify patient for home health service. Not signed by MD until 3/21/22. 2. On 12/26/21-Physician telephone order for wound care . Not signed by MD until 3/21/22 . 3. On 12/31/21-Discharge from agency form. Not signed from MD until 3/21/22. 4. On plan of care certification period 12/23/21-2/20/22, not signed by MD until 3/21/22, several months after Patient 1 expired. DPCS acknowledging delayed medical doctor signature on documents, stated, "I know this should not have occurred, we have problems with our doctors." Review of HHA document titled "Plan of Care," undated, indicated in part... "The written Plan of Care must be signed by the physician and returned to the agency within 30 days..... Signed orders will be obtained as quickly as possible...." 2. During a concurrent interview and record review on 4/5/22, starting at 3:05 p.m., Patient 5's medical record with the director of patient care services (DPCS), the record review revealed the following: a. On 2/7/2022, the certification and plan of care for 2/12/2022 - 4/12/2022, have not been signed, dated and timed by the Physician (MD). b. On 2/7/2022, a MD telephone order for medications and recertification have not been signed. c. On 2/15/2022, a MD telephone order for laboratory testing have not been signed by MD. d. 2/17/2022, MD telephone orders for medications and resumption of care have not been signed by MD. e. 3/4/2022, MD telephone orders for laboratory testing have not been signed by MD. The DPCS confirmed the missing MD signatures. DPCS further indicated that Agency "have trouble getting MD to sign all documents" in a timely manner. During a review of the facility's policy and procedure titled, "Physician/Allowed Non-Physician Practitioner (NPP) Orders," undated, indicated, "...8. A system will be used by the agency to ensure the telephone orders are signed and dated by the physician/non-physician (NPP), and returned to the client's clinical record no more than 30 days..." 3. During a review of Patient 5's medical record revealed Patient 5's most recent certification period documented on the plan of care was from 2/12/22 - 4/12/22. Patient 5 was hospitalized between 2/10/22 and 2/15/22. On resumption of care assessment dated 2/17/22, Patient 5 had four new diagnoses, gastrointestinal bleeding, diverticulosis of the large intestine without perforation, gastritis and anemia. There were also changes to the medication profile including new medication order for ferrous sulfate 325 milligrams (mg) 3 tablets by mouth daily and discontinuation of xarelto (blood thinner) 20mg 1 tablet by mouth daily. A multidisciplinary case conference conducted on 2/17/22 indicated changes needed to be made to the plan of care. No revised or updated plan of care found in medical record. During an interview on 4/5/22, at 3:25 p.m., with the director of patient care services (DPCS), the DPCS confirmed Patient 5's plan of care had not been updated to include changes in Patient 5's condition following hospitalization. 1. The facility’s policy and procedure (P&P) titled, “Plan of Care,” undated, the P&P indicated, “The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary…” During a concurrent interview and record review on 4/7/22, at 10: 29 a.m., with the Director of Patient Care Services (DPCS), DPCS reviewed Patient 7’s medical record and stated there was no updated POC after returning from a hospitalization on 3/11/22 and there should have been.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled nurse (SN 1) communicated to the agency and other personnel furnishing services, of a change in oxygen utilization necessary for one of seven patients (Patient 6). SN 1 failed to coordinate with the agency staff that Patient 6 oxygen requirements, had increased due to continued shortness of breath (SOB). This agency failure had the potential for ineffective coordination of patient care. Findings: During a review of Patient 6 plan of care (POC) dated 3/5/22 - 5/3/22, indicated, Patient 6, to use "O2 [oxygen] at 2 LPM [litters per minute] via NC [nasal cannula] PRN [as needed] at night ordered by MD." Further review of skilled nursing (SN) visits dated 3/31/22, by SN1 indicated in part, "Noted SOB, is with O2 at 3 LPM via nasal cannula...." Skilled nursing visit dated 3/22/22, by SN1 indicated in part... "Resident is alert with Oxygen at 3 LPM..." During Patient 6 home visit, Patient 6 was noted to be utilizing portable Oxygen at rate of 3 LPM. Patient 6 gives history of SOB when ambulating and now needing oxygen "24 hours a day." During an interview on 4/5/22, starting at 4:30 p.m., with Director of Patient Care Services (DPCS) while reviewing Patient 6 medical record, DPCS acknowledged that Patient 6's medical doctor had not been notified of Patient 6 need for increased oxygen both in LPM or continues need, DPCS stated, "She [SN1] should have gotten orders (from MD) for changes." During a review of HHA policy titled, "Plan of Care," undated, indicated in part..."Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care..."

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled nurse staff communicated to the agency and other personnel furnishing services, of a change in medication direction for two of seven sampled patients (Patient 6 and Patient 5). Skilled nursing staff failed coordinate with the agency staff that Patient 6 and Patient 5 were taking pain medications ordered by other unknown providers. This agency failure had the potential for ineffective coordination of patient care. During a review of Patient 5's "Skilled Nursing Visit Note" (SNV) dated 3/21/22 and 3/28/22, the SNV under the "Pain" heading indicated, Patient 5 had pain levels of 6/10. The SNV further indicated "takes tylenol or ultram (a narcotic medication used to treat moderate to severe pain) prn." During a review of Patient 5's "Plan of Care (POC), dated 2/12/22-4/12/22, the POC indicated, Patient 5 only had tylenol ordered for pain relief. A review of Physician orders dated 2/7/22 and 2/17/22 did not reveal any other pain medications being ordered. During an interview on 4/6/22 at 10:35 a.m., with the director of patient care services (DPCS), the DPCS acknowledged the discrepancy in the medication orders versus the medications being taken. DPCS indicated Patient 5 might be receiving the ultram from another physician and confirmed "this is a medication error." During an interview on 4/6/22 at 4:10 p.m., with LN2, LN2 indicated Patient 5 mostly uses tylenol for pain but will occasionally take the ultram. LN2 further stated that Patient 5's daughter controls the ultram. During a concurrent interview and record review on 4/5/22, starting at 4:30 p.m. with director of patient care services (DPCS), Patient 6's record revealed the Plan of Care (POC) dated 3/5/22-5/3/22. POC indicated in part... Patient 6 to receive "Tramadol (A narcotic to treat moderate to severe pain) 50 milligrams TID (three times a day) PRN (whenever necessary), " Record review did not include any other pain medication ordered by the HHA. Further record review indicated skilled nursing visits occurred on 3/22/22 and 3/31/22, both visits indicated Patient 6 was complaining of back pain relieved by "Oxycodone (narcotic to treat moderate to severe pain) 5 milligrams 2 times a day and Tramadol 50 milligrams 3 times day." Patient 6 record did not reveal Patient 6 medical doctor being notified of additional medication (Oxycodone) and record did not reveal any additional pain medications being prescribed after the POC. DPCS acknowledging discrepancy in medications orders versus medications being taken by Patient 6 stated, " This is a medication error, she (Patient 6) may be getting an order from another doctor, but I understand we are responsible for all medications." Review of HHA policy titled," Plan of Care", undated, indicated in part... "Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care..."

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure one of seven sampled patients (Patient7) a care conference (a meeting to identify patient needs and factors that could affect patient safety and the effectiveness of treatment) was conducted. For Patient 7, this facility failure had the potential to result in not identifying their changed needs following an unplanned hospitalization. During a review of the facility’s policy and procedure (P&P) titled, “Coordination of Client Services,” undated, the P&P indicated, “The agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment… Care conferences are conducted a week after initial visit/recertification then one month after the last conference.” During a review of Patient 7’s: a. “Recertification Assessment” (RA), dated 2/2/22, the RA indicated, certification period from 2/7/22 to 4/7/22. b. “Transfer Assessment” (TA, ) dated 3/5/22, the TA indicated, patient had almost 4 days of nausea, vomiting, and diarrhea prior to hospitalization. c. “ Resumption of Care Assessment” (RCA), dated 3/11/22, the RCA indicated, certification period from 2/7/22 to 4/7/22. During a concurrent interview and record review on 4/6/22, at 3 p.m., with the Director of Patient Care Services (DPCS), Patient 7’s medical record was reviewed. DPCS stated, “Don’t see where a care conference occurred.” DPCS further stated the care conference should have been reflected on the patient calendar online at ULTRAHHC.com. and it wasn’t.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: The CONDITION OF PARTICIPATION is not met as evidenced by: 1. The home health agency (HHA) failed to develop develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. 2. HHA failed to to develop a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law. 3. HHA failed to develop a process for tracking and securely documenting information on staff and contracted staff vaccination status and requests for exemptions. The cumulative effects of these systemic problems resulted in the facility's inability to ensure an effective infection control program that provides quality health care in a safe and sanitary patient environment. (Cross reference G687)

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: Based on interview and record review, the home health agency (HHA) failed to develop and implement policy and procedures to ensure that all staff are fully vaccinated for COVID-19. The HHA failed to develop policies and procedures ensuring staff who have pending requests for delayed vaccinations or exemptions for vaccinations, and a process for tracking and securely documenting COVID-19 vaccination status. This agency failure has the potential to transmit the COVID-19 virus to HHA patients and staff. Findings: During an interview on 4/5/22, starting at 9:20 a.m., with Director of Patient Care Services (DPCS), DPCS indicated the HHA does not have any policies or procedures for COVID-19 vaccination status for HHA staff or contracted staff. DPCS indicated they keep track of employee vaccination status by making a copy of their vaccination cards and placing in employee files. During a concurrent interview and record review on 4/5/22 at 9:45 a.m., with DPCS total of eight HHA employed staff records were reviewed for COVID-19 vaccination status. Review revealed three staff did not have records of employee vaccination status. One registered nurse employee file record indicated she had refused the vaccine for medical reasons and had been sending weekly COVID-19 test results to the HHA. DPCS acknowledged there had not been a request or approval for this one employee request for exemption, DPCS stated, “This just came through verbally.” During a review of HHA contracted employee files indicated, there is a total of five contracted physical therapists and one contracted medical social worker that work with HHA patients , HHA had no records of vaccine status of the contracted groups.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review Patient 6 has been receiving skilled nursing visits from Licensed Vocational Nurse (SN1), from start of Plan of Care (POC) certification, LVN has not received Registered Nurse (RN) monitoring to evaluate performance of provision of services. This failure has the potential to not have provision of services and treatments conducted in a appropriate clinical manner. During a concurrent interview and record review on 4/6/22, starting at 9;00 a.m., with Director of Patient Care Services (DPCS), indicated, Patient 6 weekly skilled nursing visits conducted during most recent certification dated 3/5/22 - 5/3/22, were all conducted by SN1. Further record review produced a form titled, "Supervisory Note," dated 3/16/22, the form indicated "Patient/Patient care giver verbalized happy with LVN service." The form was not signed. DPCS confirmed that RN supervision is done by telephone and consist of calls being placed to family members, DPCS stated, "I am aware we have not been doing face to face supervision of the LVN in the home."

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure Registered Nurse (RN) onsite supervisory visits for the Certified Home Health Aide (CHHA) services was completed every 14 days for two of two sampled patients (Patients 4 and 5). This HHA failure resulted in incomplete assessment of care and the potential for substandard quality of care for Patients 4 & 5 by provided by the CHHA. During a record review of Patient 5’s “Supervisory Note” for CHHA services, dated 4/4/22, there was no indication that the supervisory visit was completed on site (in home). During an interview on 4/5/2022, at 3:05 p.m., with the director of patient care services (DPCS), the DPCS indicated that all CHHA supervisory visits are done via phone call by by the RN supervisor. She further acknowledged that there are no onsite (in home) supervisory visits for Patient 5. During a record review of Patient 4’s “Supervisory Note” for CHHA services, dated 2/24/22, 3/10/22, 3/21/22, and 3/26/22, there was no indication that the supervisory visits were completed on site. During an interview on 4/6/2022, at 11:35 a.m., with the director of patient care services (DPCS), the DPCS confirmed there are no onsite (in home) supervisory visits for Patient 4. During a review of Agency’s policy and procedure P&P) titled, “Home Health Aide Supervision,” undated, the P&P indicated, “3. Supervisory visits of Home Health Aides shall be according to the following frequency: a. When skilled services are being provided to a client, a Registered Nurse/Therapist must make a supervisory visit to the client’s residence no less than every 14 days…to assess relationships and determine whether goals are being met.”

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: Based on interview and record review, the home health agency (HHA) failed to ensure two of seven sampled patients (Patient 7 and Patient 5), medical record documents were authenticated (reviewed and approved) with a date, signature, and title of the home health staff. 1. For Patient 7: Recertification Assessment, Medication Profile, Transfer Assessment, Resumption of Care Assessment, and Resumption of Care Orders. 2. For Patient 5: 60-day Summary, Resumption of Care Assessment, and Resumption of Care Orders. For Patient 7 and 5, these failures had the potential for inaccurate and incomplete medical information documented in their medical record. 2. During a review of Patient 5's: a. The Resumption of Care Assessment (RCA - an updated patient assessment document completed following a hospitalization), dated 2/17/22, indicated, “I have personally reviewed all of the above information and hereby, certify, affirm, and declare that the above information is complete, true, accurate, and correct.” The Registered Nurse (RN) signature and date were missing. b. A 60 day Summary (report of patient progress toward goals), for recertification period 12/14/21 - 2/11/22, the summary indicated, the RN signature and date were missing. During a review of the facility’s policy and procedure (P&P) titled, “Clinical Documentation,” undated, the P&P indicated, “Purpose. To ensure that there is an accurate record of the services provided, client response and ongoing need for care… A separate note shall be completed for each visit/shift and signed and dated by the appropriate professional.” 1. During a review of Patient 7’s: a. Recertification Assessment (RA), dated 2/2/22, the RA indicated, “I have personally reviewed all of the above information and hereby, certify, affirm, and declare that the above information is complete, true, accurate, and correct.” Signature and date were missing. b. Medication Profile (MP), dated 2/2/22, the MP indicated, the RN (Registered Nurse) signature was missing. c. Transfer Assessment (TA), dated 3/5/22, indicated, “I have personally reviewed all of the above information and hereby, certify, affirm, and declare that the above information is complete, true, accurate, and correct.” Signature and date were missing. d. Resumption of Care Assessment (RCA), dated 3/11/22, indicated, “I have personally reviewed all of the above information and hereby, certify, affirm, and declare that the above information is complete, true, accurate, and correct.” The signature and date were missing. e. Resumption of Care Orders (RCO), dated 3/11/22, indicated, “Order read back and verified with physician,” signature, name, discipline, and date were missing. Physician signature and date were missing. During an interview on 4/6/22, at 3 p.m., with the Director of Patient Care Services (DPCS), DPCS stated the RA, MP, TA, and RCA are missing signatures and dates.