Every finding on record at Extended Health Care, Inc.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: No 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 home health agency failed to provide care and services identified in the physician's plan of care for one of six patients (Patient 5). This deficient practice had the potential for the patient's identified needs will not be met that could impact the patient's health status and wellbeing. Findings: A review of Patient 5’s clinical record indicated she was admitted to the home health agency (HHA) with a start of care date of 11/16/2022. The diagnoses included Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breath), and abnormal weight loss. The physician plan of care included Skilled Nurse (SN) to visit the patient twice a week for one week and one time a week for eight weeks to observed/assess cardiopulmonary, musculoskeletal GI/GU system explain prescribed diet and medication regimen , clean filter of concentrator weekly and to instruct patients on disease process and measures to prevent complications and with the goal of patient's oxygen saturation being 98% in 9 weeks and able to gain at least 1LB( a unit of measurement) a month with additional food supplements in 9 weeks. Patient was on 2 liters (a unit of measure) of O2 continuous via Nasal Cannula (a device used to deliver supplemental oxygen or increase airflow to a person in need of respiratory help). During a joint home visit at Patient 5’s residence with RN 1, it was observed the RN did not assess Patient 5's current weight including the respiratory status of the patient as indicated in the physician's plan of care.

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: No findings

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 home health agency failed to promptly notify the physician by failing to: Ensure physician was notified of Patients 1 and 2's significant change of condition that resulted to patients' admission to the general acute hospital (GACH). The deficient practice has the potential to result in the non-continuity of patients' medical care needs, and the care and services would not be provided and met under the care of their primary physicians. Ensure the physician was notified of Patient 6's home health services was on hold due to the patient being out of town. This deficient practice has the potential to result in patient's medical condition not assessed for safe travel that could impact the health and safety of the patient. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 11/06/2013, with diagnoses which included respiratory distress, ventilator dependent (machine needed due to being unable to breathe effectively) and tracheostomy (an opening created in the front of the neck so a tube can be inserted into the windpipe to help a person breathe) status. A review of Patient 1's Plan of Care (POC) for the certification period of 12/02/2022 to 01/31/2022, included an order for Licensed Vocational Nurse (LVN) for 375 hours per month. The POC further indicated for the LVN to administer medications and breathing treatments as ordered and monitor effectiveness and adverse side effects of medications. A review of Patient 1’s Communication Notes dated 11/11/2022 indicated that patient was admitted to the general acute care hospital (GACH). A review of Patient 1’s clinical record indicated that the physician was not notified regarding the patient’s change of condition and that patient was admitted to the GACH. Further review of Patient 1’s clinical record indicated that there was no order to hold home health services. b. A review of Patient 2’s clinical record indicated, a start of care date 04/17/2017, spastic quadriplegic cerebral palsy (difficulty controlling movement in the arms and legs), microcephaly (condition in which a baby’s head significantly smaller than expected due to abnormal brain development), epilepsy (disorder in which the nerve cell activity in the brain is disturbed , causing seizures), dysphagia (difficulty in swallowing), tracheostomy and gastrostomy-jejunostomy (GJ - tube is placed at the stomach ad small intestine to vent the stomach from air/drainage as well as for feeding). A review of Patient 2’s Plan of Care (POC) for the certification period of 11/14/2022 to 01/13/2022, included an order for Licensed Vocational Nurse (LVN) for 480 hours per month. The POC further indicated for that the skilled nurse (SN) will assess patient's vital signs and administered medications as prescribed. A review of Patient 2’s Communication Notes dated 11/06/2022 indicated that patient was admitted to the general acute care hospital (GACH). A review of Patient 2’s clinical record indicated that the physician was not notified regarding the patient’s change of condition and that patient was admitted to the GACH. Further review of Patient 2’s clinical record indicated that there was no order to hold home health services. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 12/08/2022, at 1:37 p.m., she stated that there was no hold order for Patient 1 and Patient 2 when they were admitted to the hospital. The DPCSD further stated that when a patient is admitted to the hospital the physician should be notified and there should be orders to place home health services on hold. A review of the agency’s policy and procedure titled “Patient Placed on Hold to Home Health Services when admitted to ACF,” dated 01/15/2001, indicated that a patient is placed on hold to home health services when admitted to the hospital or ACF. c. On 12/7/22, at 10 AM, during an interview with the director of patient care services at the branch location, she stated Patient 6 has been out of town on vacation with patient caregiver. The last time the license vocational nurse visited Patient 5 was on 10/23/2022. A review of patient 6’s clinical record on 12/8/2022, indicated she was admitted to the home health agency with a start of care date of 12/2/2003. For the certification period of 9/25/2022 to 11/24/2022, and 11/24/2022 to 1/23/2023, the diagnoses included Chromosomal Abnormality (a congenital ( present at birth) disorder that causes irregularities in the DNA makeup, such as extra or missing chromosomes, unspecified, ventricular septal defect ( a heart defect due to an abnormal connection between the lower chambers of the heart ( ventricles) , and other congenital defects( an often inherited medical condition that occurs at or before birth.) Review of the 60-day summary on the plan of care for the certification period of 9/25/2022 to 11/24/2022, and certification period for 11/24/2022 to 1/23/2023, indicated “medication refilled because mother plans for vacation this November, no date yet. Continue current meds.) Review of Patient 6’s clinical record indicated a typewritten letter to the DPCS of the HHA dated 10/24/22, and a handwritten letter dated 11/21/22, informing the HHA Patient 6 was going out of town, primary physician aware, and patient caregiver will be responsible to total care of patient 6.” Review of the HHA’s OASIS Follow Up (Outcome and Assessment Information Set) from patients assessments) for the certification period of 9/25/2022 to 11/24/2024 with the assessment dated of 9/20/2022, and the OASIS follow up for the certification period of 11/24/2022 to 1/23/2023, with the assessment dated of 11/19/2022, signed by the administrator/DPCS on 11/17/2022, indicated Patient 6 was on enteral nutrition, incontinent of bowel/bladder, can walk with assistance and requires maximal help with her activities of daily living. Review of Patient 6"s clinical record indicated supervisory visit forms dated 10/27/2022, 11/17/2022, and 11/21/2022, documented LVN 2 was not present. Review of the supervisory visit form dated 11/21/2022, documented, PCG leaving today by car, reminded her to bring equipment, PCG will be updating agency about patients’ condition via phone weekly. There was no documentation in Patient 6's clinical record indicating the HHA communicated with the PCG weekly regarding Patient 6's current condition. During an interview with the administrator/director of patient care in the branch office on 12/8/22 at 10:30 AM, she stated she had not checked up with Patient 6's caregiver regarding her current condition and when she was returning from out of state. There was no documented evidence that Patient 6 was reassessed prior to her car travel, that the primary physician was informed by the HHA of Patient 6's travel out of state, approved of the travel and that the home health services were put on hold. During an interview with the Administrator/DPCS designee and the RN supervisor on 12/8/22, in the branch office, both stated the physician should have been informed of the patient going out of town, the home health services should have been put on hold, the MD should have been informed the patients should have been reassessed before travel. During further interview with the administrator/DPCS on 12/8/22, she stated she did not notify the physician or put the patients home health services on hold and could not explain the documented evidence in Patient 6's clinical record of the conducted supervisory visits on 10/27/22, 11/17/22, 11/21/22, and the completed OASIS for the certification period of 11/24/22 to 1/23/20. Patient 6 had not received skilled nursing services from the HHA since 10/23/22. Review of the home health agency’s policy on, Patient Placed on Hold to Home Health Services when Admitted to ACF, approved 1/15/2001, documents the following: 1. Patient is on hold to home health services when admitted to the hospital or ACF Hold services are for 60 days. 2. Patient is discharged from ACF, OASIS resumption or assessment will be completed by the RN. 3. If there is no change of condition, continue the same POT but assessment must be completed. Have MD order resumption of care.”

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to educate Patient 5 on the correct use of her portable oxygen tank. This deficient practice put the patient at risk for not receiving adequate oxygenation. Findings: A review of Patient 5’s clinical record indicated she was admitted to the home health agency (HHA) with a start of care date of 11/16/2022, with diagnoses of Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breath), and abnormal weight loss. The physician ordered for the skilled nurse (SN) to visit the patient twice a week for one week and one time a week for eight weeks to observed/assess cardiopulmonary, musculoskeletal GI/GU system explain prescribed diet and medication regimen , clean filter of concentrator weekly and to instruct patients on disease process and measures to prevent complications and with the goal of patient's oxygen saturation being 98% in 9 weeks and able to gain at least 1LB( a unit of measurement) a month with additional food supplements in 9 weeks. Patient was on 2 liters (a unit of measure) of O2 continuous via Nasal Cannula (a device used to deliver supplemental oxygen or increase airflow to a person in need of respiratory help). During a joint home visit in patient 5’s residence with RN 1, the RN did not assess the oxygen(O2) concentrator or is the concentrators filter had been changed weekly per the physician's order. Patient 5 stated she was not familiar/comfortable with using her new portable O2 tank and needed assistance understanding it. RN 1 never assessed her portable O2 tank, nor did she educate Patient 5 on its proper use. During an interview with the administrator designee and RN supervisor on 12/8/22, at 2pm, both stated RN 1 should have assessed Patient 5's potable O2 tank during the home visit and educated her on its use.

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 observation, interview, and record review, the home health agency (HHA) failed to ensure the policy and procedure for (COVID-19) (highly contagious respiratory disease caused by a virus that can spread from person to person) was followed and implemented. The deficient practice had the potential to put patients and staff at risk for the spread of infection. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 11/06/2013, with diagnoses which included respiratory distress, ventilator dependent (machine needed due to being unable to breathe effectively) and tracheostomy (an opening created in the front of the neck so a tube can be inserted into the windpipe to help a person breathe) status. A review of Patient 1's Plan of Care (POC) for the certification period of 12/02/2022 to 01/31/2022, included an order for Licensed Vocational Nurse (LVN) for 375 hours per month. The POC further indicated for the LVN to administer medications and breathing treatments as ordered and monitor effectiveness and adverse side effects of medications. A review of Patient 1’s Communication Notes dated 11/11/2022 indicated that patient was admitted to the general acute care hospital (GACH) due to fever desaturation (blood oxygen level drops below a normal range) and being COVID-19 positive. A review of Patient 1’s Clinical Notes indicated that LVN 1 took care of patient on 11/10/2022 from 9 a.m., to 3 p.m.. Patient 1’s Clinical Notes further indicated that patient had on and off fever and that LVN informed family member to bring patient to the hospital. b. A review of Patient 2’s clinical record indicated, a start of care date 04/17/2017, spastic quadriplegic cerebral palsy (difficulty controlling movement in the arms and legs), microcephaly (condition in which a baby’s head significantly smaller than expected due to abnormal brain development), epilepsy (disorder in which the nerve cell activity in the brain is disturbed , causing seizures), dysphagia (difficulty in swallowing), tracheostomy and gastrostomy-jejunostomy (GJ - tube is placed at the stomach ad small intestine to vent the stomach from air/drainage as well as for feeding). A review of Patient 2’s Plan of Care (POC) for the certification period of 11/14/2022 to 01/13/2022, included an order for Licensed Vocational Nurse (LVN) for 480 hours per month. The POC further indicated for that the skilled nurse (SN) will assess patient's vital signs and administered medications as prescribed. A review of Patient 2’s Communication Notes dated 11/06/2022 indicated that patient was admitted to the general acute care hospital (GACH) due to being COVID-19 positive. A review of Patient 2’s Communication Notes dated 11/12/2022 indicated that patient was discharged from GACH, but no indication if patient continued to be COVID-19 positive or already tested negative. A review of Patient 2’s Clinical Notes indicated that on 11/11/2022, LVN 1 went to the GACH with patient’s family member to assist with discharge. Patient 2’s clinical notes further indicated that LVN 1 took care of the patient from 11/11/2022 to 11/18/2022. A review of the agency’s COVID-19 Log indicated that LVN 1 was asymptomatic and tested COVID-19 negative on 11/11/2022 via antigen test (detects presence of a specific viral antigen, which indicates current viral infection). A review of LVN 1’s COVID-19 Vaccination Record Card indicated that LVN 1 received the first dose on 04/15/2021, second dose on 05/13/2021 and a booster dose on 11/14/2021. During an interview with LVN 1 on 12/06/2022, at 11:40 a.m. and 12/08/2022, at 4:21 p.m., she stated that she took care of Patient 1 on 11/10/2022 and that on 11/11/2022, patient was admitted to the hospital and was COVID-19 positive. LVN 1 stated that on 11/11/2022 she tested via antigen test and was COVID-19 negative and asymptomatic. LVN 1 stated that on 11/11/2022, Patient 2 was being discharged from the hospital after being admitted for COVID-19 and that she accompanied patient’s mother to the hospital to help with discharge. LVN 1 further stated that she only tested on 11/11/2022 and did not do another test afterwards. Additionally, LVN 1 stated that while she was taking care of Patient 1 she wore a surgical mask and that there was no N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) provided by the agency. During an interview with the Director of Patient Care Services (DPCS) on 12/06/2022, at 1:45 p.m., she stated that LVN 1 was asymptomatic and tested COVID-19 negative on 11/11/2022 and no other record indicating if she tested afterwards. During an interview with the Director of Patient Care Services Designee (DPCSD) on 12/08/22, at 11:50 a.m. and 4:11 p.m., she stated that LVN 1 should have quarantined and should not have taken care of a patient. DPCSD further stated that since agency was unaware of Patient 2’s COVID-19 status after being discharged from the GACH, LVN 1 should have been wearing an N95 mask. On 12/08/2022 at 4:25 p.m., it was observed that agency’s supply of N95 mask were all expired. A review of the agency’s policy and procedure titled “COVID-19 Vaccination,” dated 06/03/2022, indicated that the purpose of the policy and procedure is to protect and support the health and safety of the agency staff and their families, our patients/clients and their families that live with them. The policy and procedure further indicated that when booster shots become approved and available, all staff members shall receive the booster on a continual basis to be fully vaccinated from COVID-19 and its variants. A review of the agency’s policy and procedure titled “COVID-19 Management,” dated 06/22/2022, indicated that if exposed to COVID-19 and are not up to date on COVID-19 vaccinations should stay home and away from other people, and quarantine for at least five full days. The policy and procedure further indicated to not report to work and get tested, even if the you do not develop symptoms, get tested at least five days after you last had close contact with someone with COVID-19. A review of the agency’s policy and procedure titled “Supplies and Equipment,” dated 11/14/2022, indicated that the purpose of the policy and procedure is to make sure that the nursing supplies/equipment are adequate and unexpired.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: No findings

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 record review and interview, the home health agency (HHA) failed to ensure its governing body assumed full legal authority and responsibility for the operation of the agency for three of six sampled patients (Patient 1, 2, and 6). This deficient practice resulted in agency’s governing body not able to provide direct support and administrative control in the parent agency. Findings: A review of the agency's policy and procedure on governing body with the approved date 8/3/1998, indicated the governing body assumes responsibility for the operation of the agency, supervision management and agency evaluation. The purpose of the governing body included to advise home health care agency on professional issues, to adopt periodic review of written policies for implementation, to oversee the management of the agency's services. A review of the agency's organization chart indicated the governing body members included the Administrator/DPCS, CEO and the Brach Office Staff. On 12/8/22 at at the Branch office, an interview was conducted with the Administrator/DPCS, Administrator/DPCS Designee, Registered Nurse (RN) Supervisor, and Branch Office staff regarding the governing body minutes. The Administrator/DPCS and Branch Office Staff stated they were not able to show the governing body minutes that addressed the agency's supervision management, and oversight of the agency's daily operation. A review of Patient 1's clinical record indicated a start of care date (SOC) of 11/06/2013. A review of Patient 1’s Communication Notes dated 11/11/2022 indicated that patient was admitted to the general acute care hospital (GACH). A review of Patient 1’s Communication Notes dated 11/26/2022 indicated that the patient was discharged to home. A review of Patient 1’s clinical record indicated that the physician was not notified regarding the patient’s discharge from the GACH. Further review of Patient 1’s clinical record indicated that there was no order to resume home health services after patient was discharged from the GACH but the HHA continued to provide care. A review of Patient 2’s clinical record indicated, a start of care date 04/17/2017. A review of Patient 2’s Communication Notes dated 11/06/2022 indicated that patient was admitted to the general acute care hospital (GACH). A review of Patient 2’s Communication Notes dated 11/12/2022 indicated that patient was discharged from GACH. A review of Patient 2’s clinical record indicated that the physician was not notified regarding the patient’s discharge from the GACH. Further review of Patient 2’s clinical record indicated that there was no order to resume home health services after patient was discharged from the GACH but the HHA continued to provide care. A review of Patient 6’s clinical record on 12/8/2022, indicated a start of care date of 12/2/2003. A review of Patient 6’s clinical record indicated a typewritten letter to the DPCS dated 10/24/22, and a handwritten letter dated 11/21/22, informing Patient 6 was going out of town, primary physician aware, and patient caregiver will be responsible to total care of Patient 6.” During an interview and review of clinical records of Patient 1 and 2 with the Administrator/DPCS Designee and RN supervisor on 12/8/22, at 10 AM, the Administrator/DPCS Designee stated she was available to help the home health agency (HHA), however she stated she was not aware of Patient 1 and 2 being hospitalized, the patients were not put on hold for home health services, no physician orders for resumption of care, no skilled nurse assessment or resumption orders. The Administrator/DPCS designee and the RN supervisor on 12/8/22, at 10 AM, both stated the physician (MD) should have been informed of the patient going out of town, and being hospitalized, home health services should have been put on hold, the MD should have been informed to order the resumption of care. RN Supervisor stated she was not aware of all the findings and her priority was working at an Adult Day Care facility; however, she stated she would like to help the HHA. During an interview on12/8/22 at 2:30 p.m., the Administrator/Director of Patient Care Services stated she was not aware that Patient 6 had been on vacation since 10/23/22, with no skilled nurse visits, no home health hold orders, no follow-up on Patient 6's condition while out of state or the supervisory visits and OASIS (OASIS Follow Up ( Outcome and Assessment Information Set-patient-specific information used by Medicare to determine reimbursement and measure quality- facts collected together for analysis from patients assessments) assessment was completed while Patient 6 was out of town since 10/23/22. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 12/06/2022, at 3:23 p.m., and 12/07/2022 at 2:10 p.m., she stated that Patient 1 and Patient 2 did not have physicians order to resume home health services after being discharged from the hospital. The DPCS further stated that when Patient 1 was discharged from the hospital, she copied the After Visit Summary that the hospital gave to the family member, and she used that as the physician order, but she did not verify the orders with the patient’s primary physician. The DPCS further stated that when Patient 2 was discharged from the hospital, she also did the same thing and used the Written Discharge Instructions that the hospital gave to the family member, and she used that as the physician order, but she also did not verify the orders with the patient’s primary physician. Additionally, the DPCS stated that when patients are discharged from the hospital, the patients automatically go back to the agency and that there is no need for a physician’s order to resume care because the patients are home base patients and have a medical waiver. DPCS unable to provide documentation or evidence regarding not needing a physician’s order to resume care after discharge from the hospital due to being a home base patient and having a medical waiver.

Parent-branch relationship CFR(s): 484.105(d) Standard: Parent-branch relationship. This STANDARD is not met as evidenced by: No findings

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to maintain its responsibilities for policies and procedures implemented in the agency's branch, how and when management and direct care staff were shared between the parent and branch, particularly in the event of staffing shortfalls or leave coverage, and human resource management at the branch. This deficient practice resulted in agency's not able to provide direct support and administrative control in the parent office and branch office. On 12/6/22, at 10:30 a.m., during an observation of the entrance to the parent office, the survey team met the agency's Chief Executive Officer (CEO) and office staff. During an concurrent interview, the survey team requested Office Staff 1 for the current census of the parent agency and branch, list of employees in the parent agency and branch, emergency preparedness policies and procedures binder, and employee files of all staff. Office Staff 1 stated she has only been working at the parent agency for about a month and stated they did not have a current census of patients at the parent agency and the branch. Office Staff 1 overhead asking the CEO the whereabouts of the employee files. Office Staff 1 was only able to provide three employee files, that included two Registered Nurses and Office Staff 1. During another interview with Office Staff 1 on 12/9/2022, at 10:45 a.m., she stated since she has been in the agency, she stated the administrator/director of patient care services has hired a registered nurse (RN) for the parent office, however the RN has never been at the office. A review of the parent agency's emergency preparedness binder indicated the staff disaster list was not updated and the last information in the binder was dated 2019. There was no floor plan in the binder or documentation that the parent agency conducted emergency preparedness drill with staff as indicated in the emergency preparedness policy. On 12/6/22, at 11:20 a.m., the Administrator/Director of Patient Care Services (DPCS) arrived to the parent office. During a concurrent interview, the Administrator/DPCS stated to the survey team, the parent agency has one new patient and there were 11 patients at the branch office. The Administrator/DPCS stated the documents for the current census of the parent agency and employee files are all located at the branch office. The Administrator/DPCS stated she hired a registered nurse (RN 1) for the parent agency, who comes three days week and she would call the RN to see if she is available. On 12/8/22 at 2:30 p.m. at the branch office, during an interview, the Administrator/DPC, Administrator/DPCS Designee and the RN supervisor were asked regarding the continued concerns regarding lack of active RN staff at the parent agency, no employee files for 19 staff members that are working from the branch office, and list of all current census at the parent office and branch office, and staffing issues at the branch office with no hold orders for the patients hospitalized/out of town and no resumption of care without physician orders. The Administrator/DPCS Designee and RN Supervisor stated they will work on these issues. The Administrator/DCPS did not provide a response. When asked regarding documented proof of their hours worked at the agency, the Administrator/DPCS Designee and the RN supervisor stated they could not provide the documents requested. On 12/6/22, at 12:00 p.m., during an interview with RN 1 at the parent agency, she stated since the agency has one patient, she has not worked at the parent agency since she was hired on 11/7/22. RN 1 stated she works for another home health agency (HHA) where she admits patients and does supervisory visits. RN 1 stated she has not done anything for the parent agency yet. RN 1 stated she did not know who was the administrator designee or the RN supervisor. RN 1 stated she had never met them and she has been working for the HHA for about 3 weeks. A review of the agency's organization chart indicated RN 2 is the agency's quality assurance staff. During the third revisit survey from 12/6/22 to 12/9/22, telephone calls were made three times to RN 2's telephone number and voicemail messages were left. There was no reply received from RN 2.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to ensure the Outcome and Assessment Information Set (OASIS) transmitted to the Centers for Medicare & Medicaid Services (CMS) were accurate and reflected the status of the patients at the time of the assessment, one of four sampled patients (Patient 1). This failure had the potential to result in an inconsistent assessment of the patient's status transmitted to CMS that could lead to inaccurate care and payment or disbursements of services provided to the patients. Findings: A review of Patient 1's clinical record indicated a start of care date (SOC) of 11/06/2013, with diagnoses which included respiratory distress, ventilator dependent (machine needed due to being unable to breathe effectively) and tracheostomy (an opening created in the front of the neck so a tube can be inserted into the windpipe to help a person breathe) status. A review of Patient 1's Plan of Care (POC) for the certification period of 08/04/2022 to 10/03/2022, included an order for a Licensed Vocational Nurse (LVN) for 375 hours per thirty days and a Registered Nurse (RN) Supervisory visit one time per month. The POC further indicated that skilled nurse (SN) was to monitor the ventilator settings, change the trach inner cannula daily and as needed, trach care daily and in case of an emergency SN can change the trach if primary caregiver is not available. A review of Patient 1’s OASIS with an assessment date of 07/30/2022, indicated that on the Section M1033 Risk for Hospitalization, the box indicating multiple emergency department visits in the past six months was checked off. During an interview with Licensed Vocational Nurse (LVN 1) on 08/26/2022, at 1:05 p.m., she stated that Patient 1 has not had any hospitalizations. During an interview with the DPCS on 08/26/2022, at 3:12 p.m., she stated that Patient 1 has not been hospitalized in the last six months. DPCS stated that the documentation in the OASIS regarding the hospitalization was an error and that she made a mistake. On 8/26/22, when requested for a policy and procedure for OASIS, the DPCS stated she would email the policy. As of 8/28/22, no written policy was received from the agency. A review of the agency’s policy and procedure titled, “Completion of Oasis,” dated 01/07/2000, indicated that the policy is to ensure licensed personnel staff to completion of Oasis accurately and in a timely manner.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to ensure that one of four sampled patients (Patient 1) had an adequate supply of tracheostomy tubes (a tube inserted into the windpipe to help a person breathe). For Patient 1, the tracheostomy tube was last changed June 30, 2022. The deficient practice resulted in not having a supply of tracheostomy tubes for Patient 1 which has the potential to place the patient at risk for respiratory distress or death in case the tracheostomy tube was dislodged. A review of Patient 1's clinical record indicated a start of care date (SOC) of 11/06/2013, with diagnoses which included respiratory distress, ventilator dependent (machine needed due to being unable to breathe effectively) and tracheostomy (an opening created in the front of the neck so a tube can be inserted into the windpipe to help a person breathe) status. A review of Patient 1's Plan of Care (POC) for the certification period of 08/04/2022 to 10/03/2022, included an order for a Licensed Vocational Nurse (LVN) for 375 hours per thirty days and a Registered Nurse (RN) Supervisory visit one time per month. The POC further indicated that skilled nurse (SN) was to monitor the ventilator settings, change the trach inner cannula daily and as needed, trach care daily and in case of an emergency SN can change the trach if primary caregiver is not available. On 08/26/2022, at 10:15 p.m., a joint home visit with Licensed Vocational Nurse (LVN 1) was conducted at Patient 1’s residence. Director of Patient Care Services (DPCS) arrived at Patient 1’s resident on 08/26/2022 at 10:50 a.m. and joined the home visit. During an interview with LVN 1 on 08/26/2022, at 10:58 a.m. and 1:20 p.m., she stated that the last time Patient 1’s tracheostomy was changed was last February 2022, but cannot recall the date. LVN 1 also stated that the tracheostomy tube is being changed once a month by Patient 1’s family member and that she assists. A review of the treatment record indicated the trache was last changed on 2/22/2022. The treatment record for the month of July indicated there was no trache supply but did not indicate a date when the trache tube is due for change. LVN 1 further stated that when Patient 1 ran out of tracheostomy tubes, there will be no back-up supply in the event of an emergency. When asked, LVN 1 stated that she is the one who orders the patient’s trache supplies and that she had informed the DPCS regarding the low on tracheostomy tube supply but there was no follow-up. However, LVN 1 cannot remember the date DPCS was informed. During interview and concurrent record review with the DPCS on 08/26/2022, at 3:12 p.m., she stated that Patient 1’s record indicated that the last time the tracheostomy tube was changed was on 6/20/2022 and that for the month of July 2022, the tracheostomy tube was not changed because there was no supply. When asked, DPCS stated that if the tracheostomy tube gets dislodged then would reinsert the same tracheostomy tube again because the patient does not have an extra one. DPCS further stated that if worse comes to worse, then, 911 will be called. A review of Patient 1’s Communication Notes did not indicate a note that patient’s physician was notified regarding the tracheostomy tube supply. During the interview 8/26/2022 at 1:20 p.m., LVN 1 stated the family was aware that they were low in supplies. LVN 1 called to order the supplies from the supplier and was told that the trach was phased out. LVN 1 stated she did not look for another supplier. LVN 1 made an appointment with the Patient 1’s physician to see if they can switch out the trache to a different trache. LVN 1 further stated that she cannot recall the date but she had mentioned to the DPCS that the type of trache for Patient 1 was phased out and when there was low supply however, the DOCS did not follow up. On 8/27/2022 at 11:09 a.m., the surveyor called the family for an interview during the survey and had left a message, however, there was no answer and had not called back. A review of the agency’s policy and procedure titled “Ordering Supplies,” dated 12/28/1990, indicated that the family is responsible for ordering supplies and medications. The policy and procedure further indicated that the nurse can assist in the ordering of supplies and medications. Additionally, the policy and procedure indicated that the RNS (Registered Nurse Supervisor)/DON (Director of Nursing) can assist if there is a problem that cannot be resolved.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on record review, and interview, the HHA failed to furnish treatment/care for one of 4 sampled patients. The deficient practice had a potential to result in lack of care and services to meet patient's care goals. A review of Patient 1 clinical record indicated he was admitted to the home health agency with a start of care date of 4/17/2017, for the certification period of 3/19/2022- 5/18/2022, with diagnosis of spastic quadriplegic cerebral palsy (difficulty controlling movement in the arms and legs ), microcephaly (a condition in which a baby’s head I significantly smaller than expected due to abnormal brain development), epilepsy (a disorder in which the nerve cell activity in the brain is disturbed , causing seizures.), dysphagia (difficulty in swallowing), tracheostomy (an opening created in front of the neck so a tube can be inserted to help breath), gastostomy-jejunostomy tube is placed at the stomach ad small intestine to vent the stomach from air/drainage as well as for feeding). The physician instructed the Skilled Nurse (SN): License Vocation Nurse ( LVN) 480 hours/#0 days and the Registered Nurse to visit 2 hours/month for LVN supervision and case management under EPSDT program. During the entrance conference with the Director of Patient Care Service on 6/8/2022, at 10: 00 a.m., she stated Patient 1 and Patient2 are sharing the same License Vocational Nurse (LVN) due to one of the LVN’s being on Bereavement leaves since May 15, 2021. The DPCS stated Patient 1’s physician has authorized patient for skilled nurse 16 hours a day , 7 days a week however, since the HHA does not have enough staff, the HHA can only provide 3 days a week. The DPCS stated she has eleven patients who require intermittent care and that she has eleven nurses who are providing the care. During a phone interview with patient 1’s caregiver on 6/9/22, at 1: 30 p.m., she stated Patient 1’s physician has had an order for 16 hours a day , 7 days a week, however, for about five months the HHA has been only providing 5 days a week and since February 2022, the have only been able to provide 3 days a week due to the nursing shortage. The HHA has not informed her how long this schedule will continue.

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 home health agency failed to ensure that a qualified Administrator and Administrator Designee were hired to oversee the day to day operations of the agency. This failure had the potential that the provision of the agency's home health services, its operational plans, and its quality assessment and performance improvement program will not be addressed and reviewed which can affect the quality of patient care provided to all the patients receiving services from their agency due to an unqualified Administrator and designee. A review of the Administrator's employee record was conducted on 6/8/2022, at 11:44 a.m. The record did not indicate there was an application of employment, no hire date and had no credentials of being an Administrator (a personnel who's duty is to shape the policy that runs the facility and improve the patients’ experience and are essential to successful and efficient healthcare facilities), trainings and competencies were done and filed in the employee's records. During an interview on 6/8/2022, at 11:50 a.m., the Administrator stated he received his administrator's license in the Philippines (a country in Asia) in 1974. When asked if he had any certificates of completion for the Administrator training, he stated to ask the Director of Patient Care Services (DPCS). 3. A review of the DPCS designee's employee record did not indicate an application for the position nor a date of hire. The Basic Life support (the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway) certificate had expired on 6/2022. During an interview with the DPCS on 6/8/2022, at 11:50 a.m. regarding their Medical Director (a medical professional in charge of overseeing a health-care facility and ensuring it runs efficiently and smoothly), the DPCS stated the agency did not have a Medical Director since January 2022. During an interview on 6/8/2022, at 12:10 p.m., with both the Administrator and the Administrator designee, they both stated their responsibility is to pay the bills and monitor the finances. The DPCS is responsible for all the other responsibilities of the home health agency (HHA). When asked regarding who is the Governing body, they both stated to ask the DPCS, "we do not know". During the recertification revisit survey, the administrator and the administrator designee were asked if they could assist the DPCS with getting, copying patient's records requested for the survey, they both stated that it is not their job and the DPCS is the one who does it. The HHA was unable to provide documents that the administrator and administrator designee met the requirements for their respective positions. A review of the HHA's Administrator job description, under qualifications , indicated, a minimum of one year of supervisory and administrative experience in home health care or related health care service and be qualified in one of the health professions." The DPCS was unable to find a Job Description for the Administrator designee.

The following reflects the findings of the California Department of Public Health during a Recertification Survey and the branch is located at 10239 Old river school Rd. Downey, CA 90241 Representing the California Department of Public Health: Surveyor # 44749, Health Facilities Evaluator Nurse Surveyor # 36459, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Unduplicated admissions 0 Active Patients -11 Sample Size - 7 Home Visits- 3 The following Condition of Participation was not met: 484.75 Skilled Professional Services

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to review and update their policy and procedure for emergency preparedness. This deficient practice has the potential to affect the safety of the patients and put them at risk for delayed services in the event of an emergency or disaster. On 4/28/2022, a review of the agency’s emergency preparedness program was conducted. The policy and procedure provided by the Director of Patient Care Services (DPCS), indicated that the policy and procedure was drafted on 12/18/1990, approved on 12/21/1990 and effective 12/28/1990. The policy and procedure did not indicate when it was last revised. During an interview with the DPCS on 4/28/2022 at 1:45 p.m., she stated that the emergency preparedness policy and procedure has not been updated since 12/1990. A review of the agency’s policy and procedure titled “Emergency Action,” dated 12/28/1990, did not indicate how often the policy and procedure should be reviewed and updated.

The following reflects the findings of the California Department of Public Health during a Recertification Survey and the branch is located at 10239 Old River school Rd. Downey, CA 90241. Representing the California Department of Public Health: Surveyor # 44749, Health Facilities Evaluator Nurse Surveyor # 36459, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Unduplicated admissions 0 Active Patients -11 Sample Size - 7 Home Visits- 3 The following Condition of Participation was not met: 484.75 Skilled Professional Services

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 home health agency (HHA) failed to maintain an accurate, current medication profile for one of seven patients (Patients 4). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. A review of Patient 4's clinical record indicated a start of care date (SOC) of 11/06/2013, with diagnoses which included respiratory distress, ventilator dependent (machine needed due to being unable to breathe effectively) and tracheostomy (an opening created in the front of the neck so a tube can be inserted into the windpipe to help a person breathe) status. A review of Patient 4's Plan of Care (POC) for the certification period of 04/06/2022 to 06/05/2022, included an order for Licensed Vocational Nurse (LVN) for 375 hours per month. The POC further indicated for the LVN to administer medications and breathing treatments as ordered and monitor effectiveness and adverse side effects of medications. On 04/28/2022, at 10:05 p.m., a joint home visit with Licensed Vocational Nurse (LVN 3) was conducted at Patient 4’s residence. A review of Patient 4’s Medication Profile provided by the agency, indicated Patient 4 had a physician's order for Visine 0.05 percent (used to temporarily relieve eye redness, puffiness, itching, and watering that commonly occurs with allergies) one drop three times a day to both eyes. LVN 3 stated that the Visine was one drop on the left eye as needed. The Visine bottle did not have any prescription labels indicating dose and frequency. A review of Patient 4’s current medication indicated the patient takes Systane (used to relieve dry, irritated eyes. The Systane bottle did not have any prescription labels indicating dose and frequency. During an interview with LVN 3 on 04/28/2022, at 10:35 a.m., she stated that the Systane was started on 04/07/2022, and that she had not reported the new medication to the agency staff. During an interview with the DPCS on 4/28/2022, at 1:25 p.m., she stated the nurse needs to notify the agency staff right away when a patient has new medications. A review of the agency’s policy and procedure titled “Medication Regimen,” dated 05/12/2015, indicated that for continuous shift the licensed staff will update medication list daily when a new medication is ordered, any change in dosage, and discontinuance of any medication.

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 observation, interview and record review, the home health agency (HHA) failed to obtain a physician order for the administration of 250 milliliters (ml – unit of measurement) of water to the gastrostomy tube (g-tube: tube inserted to the belly that brings nutrition directly to the stomach) for one of seven patients (Patients 4). This deficient practice has the potential to place the patient at risk for aspiration (breathing foreign objects into your airways) and adverse medical reactions. A review of Patient 4's clinical record indicated a start of care date (SOC) of 11/06/2013, with diagnoses which included respiratory distress, ventilator dependent (machine needed due to being unable to breathe effectively) and tracheostomy (an opening created in the front of the neck so a tube can be inserted into the windpipe to help a person breathe) status A review of Patient 4's Plan of Care (POC) for the certification period of 04/06/2022 to 06/05/2022, included an order for a Licensed Vocational Nurse for 375 hours per month. The POC further indicated that skilled nurse is to monitor signs and symptoms of aspiration, infection, elimination, and feeding intolerance. A review of Patient 4’s Clinical Notes from 04/06/2022 to 04/11/2022, indicated that Patient 4 was receiving 250 ml of water to the g-tube three to four times a day. On 04/28/2022, at 10:05 p.m., a joint home visit with Licensed Vocational Nurse (LVN 3) was conducted at Patient 4’s residence. During an interview with LVN 3 on 04/28/2022, at 10:05 a.m., she stated that she gives Patient 4, 250 ml slow bolus (a single dose of a drug or other substance given over a short period of time) of water to the g-tube at 8:00 a.m., 12:00 p.m., after medications, 6:00 p.m., and 11:00 p.m. after medications. During an interview with the DPCS on 4/28/2022 at 1:25 p.m., she stated that Patient 4 had no physician order for the 250 ml slow bolus of water to the g-tube. A review of the agency’s policy and procedure titled “Conformance with Physician Order and Drug Regimen,” dated 01/07/2000, indicated that licensed skilled staff must comply strictly on the physician’s order.

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 interview and record review, the home health agency (HHA) failed to implement COVID-19 (highly contagious respiratory disease caused by a virus that can spread from person to person) vaccination policy and procedure for six of 16 employees (RN 1, LVN 4, LVN 5, LVN 6, LVN 7, and LVN 8). The had the potential to put the patients and staff at risk for infection. On 4/27/2022, a review of the agency’s Employee Records was conducted. The employee records indicated RN 1, LVN 4, LVN 5, LVN 6, LVN 7, and LVN 8 had no documentation that they had received the COVID-19 vaccine. During an interview with the DPCS on 4/28/2022 at 1:50 p.m., she stated that if an employee does not want to receive the COVID-19 vaccine then the employee signs the “Declination of COVID-19 Vaccine for Work Professionals” provide by the HHA. DPCS further stated that she does not require a medical or religious exemption from the employee. A review of the agency’s policy and procedure titled “COVID-19,” revised 11/11/2021, indicated that the purpose of the COVID-19 Vaccination is to protect and support the health and safety of the HHA staff and their families, their patients/clients and their families that live with them.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure that the Condition of Participation for Skilled Professional Services was met as follows: 1. The home health agency failed to ensure that Licensed Vocational Nurse (LVN 3 and LVN 9), had an updated training for the management of patients on oxygen and tracheostomy (a surgical opening created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) with ventilator (a breathing machines that help pump oxygen into the lungs) machine, and updated cardiopulmonary resuscitation (CPR, an emergency procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) for three of seven sampled patients (Patient 4, 5, and 7). For Patient 4, who was on ventilator machine, LVN 3, did not know the patient's ventilator machine setting. for Patient 5, the agency failed to implement the plan of care (POC), that indicated to monitor the patient's respiratory status. (Refer to G702). 2. The home health agency failed to implement for one of seven sampled patients, Patient 7's POC when the licensed staff did not monitor the patient for respiratory distress including shortness of breath, and to increase the oxygen to 5 liters per minute if the patient has low oxygen. The patient's POC has no parameter to increase the oxygen to 5 liters per minute. (Refer to G710). The cumulative effect of these systemic practices resulted in the failure of the home health agency's inability to deliver statutorily mandated compliance with Federal regulations for Skilled Professional Services to ensure the provision of highest quality health care services in a safe environment. Refer to G702 and G710

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure that Licensed Vocational Nurse (LVN 3 and LVN 9) had an updated training for the management of patients on oxygen and tracheostomy (a surgical opening created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) with ventilator (a breathing machines that help pump oxygen into the lungs) machine, and updated cardiopulmonary resuscitation (CPR, an emergency procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) for three of seven sampled patients (Patient 4, 5, and 7) for three of seven sampled patients (Patient 4, 5, and 7). For Patient 4 who was on ventilator machine, LVN 3, did not know the patient's ventilator machine setting. For Patient 5, the agency failed to implement the plan of care (POC), that indicated to monitor the patient's respiratory status. These deficient practices had the potential to place the patients at risk for respiratory distress or death due to the licensed staff’s lack of knowledge and current training on CPR and management of patient with ventilator machine. 2. A review of Patient 4's clinical record indicated a start of care date (SOC) of 11/06/2013, with diagnoses which included respiratory distress, ventilator dependent (machine needed due to being unable to breathe effectively) and tracheostomy (an opening created in the front of the neck so a tube can be inserted into the windpipe to help a person breathe) status A review of Patient 4's Plan of Care (POC) for the certification period of 04/06/2022 to 06/05/2022, included an order for a Licensed Vocational Nurse (LVN) for 375 hours per month. The POC further indicated that skilled nurse (SN) was to monitor the ventilator settings, change the trach inner cannula daily and as needed, trach care daily and in case of an emergency SN can change the trach if primary caregiver is not available. On 04/28/2022, at 10:05 p.m., a joint home visit with Licensed Vocational Nurse (LVN 3) was conducted at Patient 4’s residence. A review of Patient 4’s POC provided by the agency, indicated that the patient’s ventilator model/type was HT50 with settings that included SIMV (synchronized intermittent mandatory ventilation) mode, TV (tidal volume) 400, VR (vent rate) 12, PtPR (Pt. Pressure Rate) 18, PS (pressure support) 8, FiO2 (fraction of inspired oxygen) 21% (percent), HA (high alarm) 35-45 and LA (low alarm) 4-5. During an interview with LVN 3 on 04/28/2022, at 11:00 a.m., she stated that she is not familiar with the settings and that a Respiratory Therapist (RT) from the supplier comes if the ventilator settings need to be changed. The LVN further stated that she received ventilator training when she started as an LVN 12 years ago and has not received any current in-service or training. A review of Patient 4’s Ventilator Assessment from 03/17/2022 to 04/02/2022, indicated that the ventilator model/type was HT70, the PtPr was 12 to 13 and the LA was 6. A review of LVN 3’s employee record, indicated that she had no ventilator training certificate on file and that her CPR certification had expired on 05/2021. During an interview with the DPCS on 4/28/2022 at 1:25 p.m., she stated that the LVN needs to know the ventilator settings so that she can check if the settings are correct. The DPCS confirmed that Patient 4’s ventilator settings on the Plan of Care and the Ventilator Assessment that LVN 3 documented did not match. The DPCS was unable to provide documentation that LVN 3 had recent ventilator training and an updated CPR certificate. A review of the agency’s policy and procedure titled “Staff In-Services,” dated 01/07/2000, indicated that the purpose of the policy and procedure is to improve staff knowledge and skills in providing care to the patient and maintain a record to monitor the area of needs and best practices. 1. A review of Patient 5's clinical record indicated a Start of Care (SOC) date of 09/29/2008, with diagnoses which included traumatic brain injury (brain dysfunction cause by a violent blow to the head) and tracheostomy. A review of Patient 5's POC for the certification period of 04/03/2022 to 06/02/2022, included an order for LVN 480 hours per 30 days. The POC further indicated for the SN is to monitor the respiratory status and apply cool mist as needed, clean daily and change tracheostomy, every 7 days and as needed, and in case of an emergency SN can change the tracheostomy during the shift. On 04/28/2022, at 10:00 a.m., a joint home visit with LVN 9 was conducted at Patient 5’s residence. Patient 5 was observed in bed with tracheostomy to cool mist. During an interview with LVN 9 on 04/28/2022, at 10:50 a.m., she stated she received ventilator and tracheostomy training when she started as an LVN 13 years ago and has not received anymore in-services or training from the HHA after that period. During an interview with the DPCS on 4/28/2022 at 1:25 p.m., she stated she did not have any evidence or documentation of recent ventilator and tracheostomy training for the staff. A review of the agency’s policy and procedure titled “Staff In-Services,” dated 01/07/2000, indicated that the purpose of the policy and procedure is to improve staff knowledge and skills in providing care to the patient and maintain a record to monitor the area of needs and best practices.

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 observation, interview and record review, the home health agency (HHA) failed to ensure that the plan of care (POC) included parameters for oxygen levels and significant oxygen results to be coordinated to the physician for one of seven sampled patients (Patient 7). This deficient practice has the potential to place the patient at risk for respiratory distress that could lead to respiratory complications and or death. A review of Patient 7's clinical record indicated a start of care date (SOC) of 08/08/2011, with diagnoses which included cerebral palsy (weakness or problems with using the muscles), hypoventilation (breathing that is too shallow or too slow to meet the needs of the body), and hypoxia (an abnormally low concentration of oxygen in the blood). A review of Patient 7's POC for the certification period of 02/04/2022 to 04/05/2022, included an order for a Licensed Vocational Nurse (LVN) for 171 hours per month. The POC further indicated that skilled nurse (SN) is to monitor for signs or symptoms of respiratory distress such as shortness of breath , oxygen 2 liters per minute (LPM) as needed and may increase to 5 LPM when oxygen saturation is low. During an interview with the Director of Patient Care Services (DPCS) on 4/28/2022, at 12 p.m., DPCS confirmed the POC did not include parameters for normal oxygen saturation level but should be included in the POC. DPCS stated normal oxygen saturation level is 95 % - 100 % and anything below 95% is abnormal. A review of the agency’s policy and procedure titled “Plan of Care,” dated 12/31/1999, indicated that the purpose of the POC is for the plan to reflect orders and recommendations, coordinated services, plans and goals are consistent with patient's needs, all components have been addressed, and plan reflects medical necessity and appropriate level of skills required.

Home health aide qualifications CFR(s): 484.80(a) Standard: Home health aide qualifications. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to employ Certified Home Health Aid (CHHA) as indicated in their HHA license. The deficient practice has the potential for the CHHA services will not be met to provide patient's care and services. On 4/27/2022, a review of the agency’s Employee Records was conducted. During the review of the agency’s employee records it indicated there were no CHHA records to be reviewed. During an interview with the DPCS on 4/27/2022, at 12:05 p.m., she stated that the agency currently does not have any CHHAs employed. The DPCS further stated that the last time CHHA was employed at the agency was in 05/2017.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure 7 of 14 staffs (RN 1, LVN 1, LVN2, LVN3, LVN4, LVN5, and LVN 6) maintained valid CPR cards. This failure had the potential to result in the lack of staff's knowledge and not able to respond effectively during an emergency which required cardiopulmonary resuscitation (chest compressions often combined with artificial ventilation to maintain blood circulation). During a review of the agency's undated document entitled "applicant credentials checklist, valid and unexpired" on 4-28-22, at 12:00 p.m., required all applicants to possess and maintain a valid CPR card upon hire and throughout employment. A review of personnel records for RN 1, LVN 1, LVN2, LVN3, LVN4, LVN5, and LVN 6 revealed no documented evidence their CPR cards were maintained and valid. During an interview with the Director of patient care services (DPCS) 0n 4-8-22 at 12:10pm, DPCS stated that " CPR cards should be valid and was not for 1 RN and 6 LVN's. DPCS also stated "it is important to have a current CPR card because criteria is always changing and staff should have the latest information, this was not done and will be corrected.