Every finding on record at First Priority Home Health Care, Inc

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing care to home bound patients [patients with difficulty leaving the house]) failed to ensure the Conditions of Participation regarding Patient Rights was met as follows: 1. The Home Health Agency (HHA) failed to ensure six of six sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, and Patient 15) provided consent and received information regarding their rights in a language that would be understood and preferred by the patients. (Refer to G412) This deficient practice resulted in the patients not being informed and having a lack of understanding of the HHA’s care and services available for the patients and their families. This deficient practice resulted in patients not being able to exercise their right to receive or decline home health services.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure six of six sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, and Patient 15) provided consent and received information regarding their rights as a home health patient, in a language that would be understood and preferred by the patients. This deficient practice resulted in the patients not being informed and having a lack of understanding of the HHA’s care and services available for the patients and their families. This deficient practice resulted in patients not being able to exercise their rights to receive or decline the home health services. D. During a record review of Patient 13’s admission record, the admission record indicated a Start of Care (SOC) date of 7/27/2024, with a primary diagnosis of hypertensive heart disease without heart failure (a heart condition that occurs when someone has chronic high blood pressure but doesn't have heart failure). During a record review of Patient 13’s Plan of Care (POC), dated 7/27/2024, the POC indicated Patient 13’s primary language is Armenian. During a joint home visit on 9/5/2024 at 11:00 a.m., at Patient 13’s residence with Registered Nurse 1 (RN 1), Patient 13 was observed sitting in the chair, was awake, alert, and oriented to person, place, and time. During a joint home visit on 9/5/2024 at 11:00 a.m., at Patient 13’s residence with RN 1, observed RN 1 speaking to Patient 13 in Armenian. During a concurrent observation and interview on 9/5/2024 at 11:05 a.m. with Patient 13, Patient 13 stated her primary language that she speaks and reads is Armenian, she does not speak, understand, or read in English. During an observation on 9/5/2024 at 12:00 p.m., of Patient 13’s HHA binder, it indicated all forms including Client Consent/recertification and Patients’ Bill of Right and Responsibilities were in English. During a concurrent interview and record review on 9/6/2024 at 11:40 a.m. with Director of Patient Care Services (DPCS), Patient 13’s consents and patient’s bill of right and responsibilities were reviewed. DPCS stated the consents and patient’s bill of rights and responsibilities are all in English. DPCS stated the HHA only has consent in English, not in other languages. DPCS further stated negative outcome of not having consents in other languages that serve their patient population is that the patients will not be able to read and understand what they are signing. E. During a record review of Patient 14’s admission record, the admission record indicated a Start of Care (SOC) date of 7/20/2024, with a primary diagnosis of Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). During a record review of Patient 14’s Plan of Care (POC), dated 7/20/2024, the POC indicated Patient 14’s primary language is Spanish. During a phone interview in Spanish on 9/6/2024 at 10:40 a.m. with Patient 14, she stated she does not speak or understand English. Patient 14 stated all the paperwork she signed for the HHA was in English and she did not understand what she was signing. During a concurrent interview and record review on 9/6/2024 at 11:45 a.m. with Director of Patient Care Services (DPCS), Patient 14’s consents and patient’s bill of right and responsibilities were reviewed. DPCS stated the consents and patient’s bill of rights and responsibilities are all in English. DPCS stated the HHA only has consent in English, not in other languages. DPCS further stated negative outcome of not having consents in other languages that serve their patient population is that the patients will not be able to read and understand what they are signing. F. During a record review of Patient 15’s admission record, the admission record indicated a Start of Care (SOC) date of 6/7/2024, with a primary diagnosis of other intervertebral disc degenerative disease (recondition of the discs between vertebrae with loss of cushioning, fragmentation and herniation relating to age, where the spine loses flexibility and bone spurs may pinch a nerve root causing pain and weakness.) During a record review of Patient 15’s Plan of Care (POC), dated 6/7/2024, the POC indicated Patient 14’s primary language is Spanish. During a phone interview in Spanish on 9/4/2024 at 10:55 a.m. with Patient 15, he stated he does not speak or understand English. Patient 15 stated all the paperwork he signed for the HHA was in English and he did not understand what he was signing. During a concurrent interview and record review on 9/6/2024 at 11:50 a.m. with Director of Patient Care Services (DPCS), Patient 15’s consents and patient’s bill of right and responsibilities were reviewed. DPCS stated the consents and patient’s bill of rights and responsibilities are all in English. DPCS stated the HHA only has consent in English, not in other languages. DPCS further stated negative outcome of not having consents in other languages that serve their patient population is that the patients will not be able to read and understand what they are signing. During a record review of the HHA’s policy and procedure, titled “Patients Bill of Rights” revised November 2022, the policy and procedure indicated, “The organization shall provide verbal and written notice of the patient's rights and responsibilities in the patient's primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the completion of the second (2nd) visit from a skilled professional…” During a review of Patient 10’s Admission record, the admission record indicated a Start Of Care (SOC) date of 6/26/2024, with a primary diagnosis of other specified polyneuropathy (a disease that affects many nerves in the body at the same time). During a review of Patient 10’s Home Health Certification and Plan Of Care (POC) for the certification period of 6/26/2024 to 8/24/2024, the POC indicated, Patient 10’s primary language is Spanish. During a phone interview on 9/4/2024 at 12:15pm with Patient 10, Patient 10 stated he only speaks Spanish and needs translation when communicating or reading in English. Patient 10 further stated he could not remember the forms he signed when signing up with the HHA and when being discharged from the HHA, as the forms were many and they were in English. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 10’s undated, Patient Consent for Treatment form, was reviewed. Patient 10’s Patient Consent for Treatment form indicated, all wording was in English and had Patient 10’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 10’s “Patient Discharge Instructions”, dated 8/20/2024, was reviewed. Patient 10’s Patient Discharge Instructions” indicated all wording was in English and had Patient 10’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. b. During a review of Patient 11’s admission record, the admission record indicated a Start Of Care (SOC) date of 8/9/2024, with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure [force of your blood pushing against the walls of your arteries] that is present over a long time). During a review of Patient 11’s Home Health Certification and Plan Of Care (POC) for the certification period of 8/9/2024 to 10/7/2024, the POC indicated, Patient 11’s primary language is Armenian. During a joint home visit on 9/5/2024 at 12pm, at Patient 11’s residence with Registered Nurse 1 (RN 1), Patient 11 was observed sitting on the couch, awake, alert, and oriented to person, place, and time, and speaking Armenian. During a joint home visit on 9/5/2024 at 12pm, at Patient 11’s residence with Registered Nurse 1 (RN 1), RN 1 stated Patient 11 only spoke Armenian and RN 1 had to translate for Patient 11, as Patient 11 did not understand or speak English. During a joint home visit on 9/5/2024 at 12pm, at Patient 11’s residence with Registered Nurse 1 (RN 1), RN 1 was observed translating Patient 11’s Consent for Treatment forms that were in English to Patient 11, as Patient 11 was unable to read English. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 11’s Patient Consent for Treatment form, dated 8/9/2024, was reviewed. Patient 11’s Patient Consent for Treatment form indicated, all wording was in English and had Patient 11’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. c. During a review of Patient 12’s admission record, the admission record indicated a Start Of Care (SOC) date of 7/25/2024, with a primary diagnosis of polyosteoarthritis, unspecified (having arthritis [inflammation of the joint] that affects five or more joints at the same time). During a review of Patient 12’s Home Health Certification and Plan Of Care (POC) for certification period of 7/25/2024 to 9/22/2024, the POC indicated, Patient 12’s primary language is Spanish. During a phone interview on 9/6/2024 at 11:58am with Patient 12’s daughter, the daughter stated Patient 12 and herself speak Spanish and they do not speak English. Patients 12’s daughter further stated, Patient 12 was unable to review the consent forms she signed as they were in English and Patient 12 cannot read in English. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 12’s Patient Consent for Treatment form, dated 7/24/2024, was reviewed. Patient 12’s Patient Consent for Treatment form indicated, all wording was in English and had Patient 12’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. During a review of the HHA’s Policy and Procedure (P&P) titled, “Informed Consent/Refusal of Treatment”, with a revised date of November 2022, indicated, “Upon admission and throughout the course of care/service, the patient and family/caregiver will be: 1. Given information, in an understandable language, to make informed decisions regarding the care/service being provided.” During a review of Patient 10’s Admission record, the admission record indicated a Start Of Care (SOC) date of 6/26/2024, with a primary diagnosis of other specified polyneuropathy (a disease that affects many nerves in the body at the same time). During a review of Patient 10’s Home Health Certification and Plan Of Care (POC) for the certification period of 6/26/2024 to 8/24/2024, the POC indicated, Patient 10’s primary language is Spanish. During a phone interview on 9/4/2024 at 12:15pm with Patient 10, Patient 10 stated he only speaks Spanish and needs translation when communicating or reading in English. Patient 10 further stated he could not remember the forms he signed when signing up with the HHA and when being discharged from the HHA, as the forms were many and they were in English. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 10’s undated, Patient Consent for Treatment form, was reviewed. Patient 10’s Patient Consent for Treatment form indicated, all wording was in English and had Patient 10’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 10’s “Patient Discharge Instructions”, dated 8/20/2024, was reviewed. Patient 10’s Patient Discharge Instructions” indicated all wording was in English and had Patient 10’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. b. During a review of Patient 11’s admission record, the admission record indicated a Start Of Care (SOC) date of 8/9/2024, with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure [force of your blood pushing against the walls of your arteries] that is present over a long time). During a review of Patient 11’s Home Health Certification and Plan Of Care (POC) for the certification period of 8/9/2024 to 10/7/2024, the POC indicated, Patient 11’s primary language is Armenian. During a joint home visit on 9/5/2024 at 12pm, at Patient 11’s residence with Registered Nurse 1 (RN 1), Patient 11 was observed sitting on the couch, awake, alert, and oriented to person, place, and time, and speaking Armenian. During a joint home visit on 9/5/2024 at 12pm, at Patient 11’s residence with Registered Nurse 1 (RN 1), RN 1 stated Patient 11 only spoke Armenian and RN 1 had to translate for Patient 11, as Patient 11 did not understand or speak English. During a joint home visit on 9/5/2024 at 12pm, at Patient 11’s residence with Registered Nurse 1 (RN 1), RN 1 was observed translating Patient 11’s Consent for Treatment forms that were in English to Patient 11, as Patient 11 was unable to read English. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 11’s Patient Consent for Treatment form, dated 8/9/2024, was reviewed. Patient 11’s Patient Consent for Treatment form indicated, all wording was in English and had Patient 11’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. c. During a review of Patient 12’s admission record, the admission record indicated a Start Of Care (SOC) date of 7/25/2024, with a primary diagnosis of polyosteoarthritis, unspecified (having arthritis [inflammation of the joint] that affects five or more joints at the same time). During a review of Patient 12’s Home Health Certification and Plan Of Care (POC) for certification period of 7/25/2024 to 9/22/2024, the POC indicated, Patient 12’s primary language is Spanish. During a phone interview on 9/6/2024 at 11:58am with Patient 12’s daughter, the daughter stated Patient 12 and herself speak Spanish and they do not speak English. Patients 12’s daughter further stated, Patient 12 was unable to review the consent forms she signed as they were in English and Patient 12 cannot read in English. During a concurrent interview and record review on 9/6/2024 at 12:15pm with the DPCS, Patient 12’s Patient Consent for Treatment form, dated 7/24/2024, was reviewed. Patient 12’s Patient Consent for Treatment form indicated, all wording was in English and had Patient 12’s signature. The DPCS stated the HHA did not have Consent forms in any other language other than English and she was not aware that Consent forms were provided in other languages. D. During a record review of Patient 13’s admission record, the admission record indicated a Start of Care (SOC) date of 7/27/2024, with a primary diagnosis of hypertensive heart disease without heart failure (a heart condition that occurs when someone has chronic high blood pressure but doesn't have heart failure). During a record review of Patient 13’s Plan of Care (POC), dated 7/27/2024, the POC indicated Patient 13’s primary language is Armenian. During a joint home visit on 9/5/2024 at 11 a.m., at Patient 13’s residence with Registered Nurse 1 (RN 1), Patient 13 was observed sitting in the chair, was awake, alert, and oriented to person, place, and time. During a joint home visit on 9/5/2024 at 11 a.m., at Patient 13’s residence with RN 1, RN 1 was observed speaking to Patient 13 in Armenian. During a concurrent observation and interview on 9/5/2024 at 11:05 a.m. with Patient 13, Patient 13 stated her primary language that she speaks, and reads is Armenian. She does not speak, understand, or read in English. During an observation on 9/5/2024 at 12 p.m., of Patient 13’s HHA binder, it indicated all forms including Client Consent/recertification and Patients’ Bill of Right and Responsibilities were in English. During a concurrent interview and record review on 9/6/2024 at 11:40 a.m. with the Director of Patient Care Services (DPCS), Patient 13’s consents and patient’s bill of right and responsibilities were reviewed. The DPCS stated the consents and patient’s bill of rights and responsibilities are all written in English. The DPCS stated the HHA only has consents in English, not in other languages. The DPCS further stated the negative outcome of not having consents, in other languages, that serve their patient population is that the patients will not be able to read and understand what they are signing. E. During a record review of Patient 14’s admission record, the admission record indicated a Start of Care (SOC) date of 7/20/2024, with a primary diagnosis of diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a record review of Patient 14’s Plan of Care (POC), dated 7/20/2024, the POC indicated Patient 14’s primary language is Spanish. During a phone interview in Spanish on 9/6/2024 at 10:40 a.m. with Patient 14, she stated she does not speak or understand English. Patient 14 stated all the paperwork she signed for the HHA was in English and she did not understand what she was signing. During a concurrent interview and record review on 9/6/2024 at 11:45 a.m. with the Director of Patient Care Services (DPCS), Patient 14’s consents and patient’s bill of right and responsibilities were reviewed. DPCS stated the consents and patient’s bill of rights and responsibilities are all in English. DPCS stated the HHA only has consents in English, not in other languages. The DPCS further stated the negative outcome of not having consents in other languages, that serve their patient population, is that the patients will not be able to read and understand what they are signing. F. During a record review of Patient 15’s admission record, the admission record indicated a Start of Care (SOC) date of 6/7/2024, with a primary diagnosis of other intervertebral disc degenerative disease (recondition of the discs between vertebrae with loss of cushioning, fragmentation and herniation relating to age, where the spine loses flexibility and bone spurs may pinch a nerve root causing pain and weakness.) During a record review of Patient 15’s Plan of Care (POC), dated 6/7/2024, the POC indicated Patient 14’s primary language is Spanish. During a phone interview in Spanish on 9/4/2024 at 10:55 a.m. with Patient 15, he stated he does not speak or understand English. Patient 15 stated all the paperwork he signed for the HHA was in English and he did not understand what he was signing. During a concurrent interview and record review on 9/6/2024 at 11:50 a.m. with the Director of Patient Care Services (DPCS), Patient 15’s consents and patient’s bill of right and responsibilities were reviewed. DPCS stated the consents and patient’s bill of rights and responsibilities are all in English. DPCS stated the HHA only has consents in English, not in other languages. DPCS further stated the negative outcome of not having consents, in other languages, that serve their patient population is that the patients will not be able to read and understand what they are signing. During a record review of the HHA’s policy and procedure, titled “Patients’ Bill of Rights” revised November 2022, the policy and procedure indicated, “The organization shall provide verbal and written notice of the patient's rights and responsibilities in the patient's primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the completion of the second (2nd) visit from a skilled professional…” During a review of the HHA’s Policy and Procedure (P&P) titled, “Informed Consent/Refusal of Treatment”, with a revised date of November 2022, indicated, “Upon admission and throughout the course of care/service, the patient and family/caregiver will be: 1. Given information, in an understandable language, to make informed decisions regarding the care/service being provided.”

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey at the new agency address at 120 N Victory Blvd, Suite 306, Burbank CA 91502 from 10/11/2023 to 10/13/2023. Intake No: 101667 Representing the California Department of Public Health: Surveyor #22303, Health Facilities Evaluator Nurse Surveyor #44186, Health Facilities Evaluator Nurse Active Patients - 44 Unduplicated Admissions - 151 Sample Size – 9 Home Visit - 3 The following Conditions of Participation (COP) were not met: 484.60 - Care planning, Coordination of services, & Quality of care 484.110 - Clinical records

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview, and record review the HHA failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare (a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities program) for Care Planning, Coordination, Quality of Care was met as follows: . 1. The home health agency (HHA) failed to ensure care and services were provided in accordance with the plan of care (POC, documents the process of identifying a patient's needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers) for one of nine sampled patients (Patient 7). Patient 7's POC included skilled nurse (SN) services to conduct skilled observation and assessment of all body system twice a week for 2 weeks, and once a week for 7 weeks. SN failed to implement and provide the services as indicated in the POC due to missing SN visits. (Refer to G572). 2. The Home Health Agency (HHA) failed to develop an individualized plan of care for four of nine sampled patients (Patient 3, Patient 5, Patient 8, and Patient 9). (Refer to G574). 3. The Home Health Agency (HHA) failed to ensure the physician was notified of the care and services not rendered for one of nine sampled patients (Patient 7). (Refer to G602). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal Regulations for Care Planning, Coordination, and Quality of Care to ensure the highest quality health care is provided to patients certified to receive home health services.

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 (HHA) failed to ensure care and services are provided in accordance with the plan of care (POC), for one of nine sampled patients (Patient 7). Patient 7's POC included skilled nurse (SN) services to conduct skilled observation and assessment of all body system twice a week for 2 weeks, and once a week for 7 weeks. SN failed to implement and provide the services as indicated in the POC due to missing SN visits. This deficient practice resulted for Patient 7 not to receive the care and services as ordered in the POC that could affect the patient's health status and wellbeing. Findings: A review of Patient 7's admission record indicated a start of care date (SOC) of 9/10/2023, with diagnoses that included hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and hemiplegia (paralysis of one side of the body). A review of Patient 7's Home Health Certification and Plan of Care (POC) for the certification period from 9/10/2023 to 11/8/2023, indicated for the skilled nurse (SN) to visit two times a week for two weeks, then once a week for 7 weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate), pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a telephone interview on 10/12/23, at 9:15 a.m., with Patient 7, Patient 7 stated she was only visited one time by the SN since the start of care (unidentified time and date). During a concurrent interview and record review, on 10/13/23, at 1:50 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 7’s SN visit notes during the week of 9/17/2023 to 9/23/2023 were reviewed, The DPCS stated there was no documented evidence of the SN observation and assessment of patient's all body systems was conducted twice a week. The DPCS stated she was unable to provide documented evidence that Patient 7 was visited twice in accordance with the plan of care for the week period of 9/17/2023 to 9/23/2023. A review of the agency's policy and procedure titled, "Care Planning Process," revised November 2022, indicated the plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. The patient-specific clinical plan of care includes frequency and duration of visits.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, Home Health Agency (HHA) failed to develop an individualized plan of care (documents the process of identifying a patient's needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers) for four of nine sampled patients (Patient 3, Patient 5, Patient 8, and Patient 9). This deficient practice resulted for Patient 3, Patient 5, Patient 8, and Patient 9 not to have a plan of care to identify the patient's care and needs. Findings: b. A review of Patient 5's admission record indicated a start of care date of 9/15/23, with a diagnosis that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), and benign prostatic hyperplasia (enlarged prostate gland). On 10/11/23 at 3:45 p.m., during a joint record review of Patient 5’s electronic heath record and interview with the Intake Coordinator (IC 1), a request was made from IC 1 to provide a copy of the patient’s POC. IC 1 stated, “Can you give me 10 minutes please, we don’t have it yet in our system”. c. A review of Patient 8's admission record indicated a start of care date of 10/1/23, with a diagnosis that included type 2 diabetes mellitus, hypertension (high blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). On 10/13/23 at 1:35 p.m., a request was made from IC 1 to provide a copy of Patient 8’s POC. IC 1 stated the agency does not have patient’s POC yet. On 10/13/23 at 1:50 p.m., during an interview and joint record review with the Director of Patient Care Services designee (DPCSD), the DPCSD stated the plan of care supposed to be completed within a week after the initial comprehensive assessment was done by the registered nurse. DPCSD stated and acknowledged the finding. A review of the agency's policy and procedure titled, "Care Planning Process", revised November 2022, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. a. A review of Patient 3's admission record indicated a start of care date of 9/30/23, with a diagnosis that included hypertension osteoarthritis ( occurs when flexible tissue at the ends of bone wears down). On 10/11/23 at 2 p.m., during a joint record review of Patient 3's electronic heath record with the IC 1 (intake coordinator), indicated there was no documented evidence of a POC (plan of care) found in their computer system. During an interview with IC 1,when asked to print a copy of the POC, she stated that there was no POC developed for this patient at this time. b. A review of Patient 9's admission record indicated a start of care date of 9/30/23, with a diagnosis that included hypertension ( a condition in which the force of the blood against the artery walls is too high). On 10/11/23 at 2:30 p.m., during a joint record review of Patient 9’s electronic heath record with the IC 1 (intake coordinator), indicated there was no documented evidence of a POC (plan of care) found in their computer system. During an interview with IC 1, when asked to print a copy of the POC, she stated that there was no POC developed for this patient at this time.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the physician was notified of the care and services not rendered for one of nine sampled patients (Patient 7). This failure had the potential for Patient 7's status to decline with no immediate interventions due to the lack of physician notification by the HHA. Findings: A review of Patient 7's admission record indicated a start of care date (SOC) of 9/10/2023, with diagnoses that included hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and hemiplegia (paralysis of one side of the body). A review of Patient 7's Home Health Certification and Plan of Care (POC) for the certification period from 9/10/2023 to 11/8/2023, indicated that a skilled nurse (SN) was scheduled to visit two times a week for two weeks, then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate), pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a concurrent interview and record review, on 10/13/2023 at 1:50 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 7’s SN visit notes dated from 9/17/2023 to 9/23/2023 were reviewed. the DPCSD stated Patient 7 was only visited one time and there was no documented evidence the physician was notified of the missed visits. The DPCSD stated for any missed visit, patient’s attending physician should be notified promptly per the agency’s policies and procedures. DPCS stated and acknowledged the finding. A review of the agency’s policy and procedure titled, “Missed Visits”, revised November 2022, indicated missed visit will be communicated to the clinical supervisor and the patient’s physician. If a visit is missed and not rescheduled, the clinician will notify the physician and clinical supervisor of the missed visit and reason for missed visit. A review of the agency’s policy and procedure titled, “Monitoring Patient’s Response/Reporting to Physician”, revised November 2022, indicated clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. The patient’s physician will be contacted on the same day when any of the following occur: when a visit is missed for any reason.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure pain reassessment was conducted in accordance with the plan of care for one of 9 sampled patients (Patient 6). This deficient practice has the potential to result in ineffective pain management. Findings: A review of Patient 6's admission record indicated a start of care date (SOC) of 7/6/23, with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of Patient 6’s OASIS (Outcome and Assessment Information Set, is the patient-specific, standardized assessment used in home health care), dated 7/6/23, indicated Patient 6 was experiencing an aching low back pain with an intensity of 3 (mild -noticeable, distracting)/10 (scale of 0-10, 0 being no pain and 10 being the worst pain). The pain was relieved with rest, repositioning, relaxation, medication, and diversion. A review of Patient 6's Home Health Certification and Plan of Care (POC) for the certification period from 7/6/23 to 9/3/23, indicated that a skilled nurse (SN) was scheduled to visit once a week for 1 week, then twice a week for 2 weeks, and once a week for 7 weeks for skilled observation and assessment of all body systems, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), check location, intensity and severity of pain, implement pain relief measures and evaluate its effectiveness, and perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate). A review of Patient 6's Clinical Nursing Notes dated 9/10/23, and 10/4/23 indicated Patient 6 was experiencing lower back pain 3/10 (mild). On 9/27/23, Patient 6 was experiencing lower back pain 4/10 (moderate). There was no documented evidence pain intervention and reassessment was conducted by the SN. On 10/13/23 at 1:50 p.m., during an interview and joint record review with the Director of Patient Care Services designee (DPCSD), the DPCSD stated pain assessment should include pain intervention that was implemented and the effectiveness of the intervention. The DPCSD acknowledged pain management assessment was not done. A review of the agency’s policy and procedure titled, "Pain Assessment", revised November 2022, indicated when pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient’s condition. When the patient or the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible: present pain management regimen and effectiveness.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Clinical Records was met as follows: 1. The home health agency failed to ensure pertinent clinical records were included to accurately reflect the care and assessment for seven of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, and Patient 9). This failure resulted in patients' incomplete clinical records. (Refer to G1012) 2. The home health agency failed to ensure patient care records were safeguarded for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential for the records not being protected and putting the patient's confidential information at risk for unauthorized use by unauthorized personnel. (Refer to G1028) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal Regulations for Clinical records ensure confidentiality and security of these clinical records are maintained to its accuracy, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. The cumulative effect of this systemic practice resulted in the failure of the HHA to ensure the provision of a quality health care in a safe environment.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure pertinent clinical information were included to accurately reflect the care and assessment for seven of 9 sampled patients (Patients 1, 2, 3, 4, 5, 8, and 9). This failure has the potential to result in patient’s incomplete clinical record that could lead to misinformation and lack in the continuity of care and services provided to the patient. Findings: b. A review of Patient 4's admission record indicated a start of care date (SOC) of 9/15/23, with a diagnosis that included radiculopathy lumbar region (a pain syndrome caused by compression or irritation of nerve roots in the lower back), hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Patient 4's Home Health Certification and Plan of Care (POC) for the certification period from 9/15/23 to 11/13/23, indicated that a skilled nurse (SN) was scheduled to visit once for the first week, then twice a week for one week, and then once a week for 7 weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate), and to teach patient and patient caregiver (Pcg) on medication regimen and pain control measures. On 10/11/23 at 3:45 p.m., during a joint record review of Patient 4’s electronic heath record with the Intake Coordinator (IC 1), a request was made from IC 1 to provide a copy of the patient’s SN visit notes. IC 1 was not able to provide copies and stated the visiting nurse has not submitted the notes since the SOC. c. A review of Patient 5's admission record indicated a start of care date of 9/15/23, with a diagnosis that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), hypertensive heart disease, and benign prostatic hyperplasia (enlarged prostate gland). On 10/11/23 at 3:45 p.m., during a joint record review of Patient 5’s electronic heath record with the Intake Coordinator (IC 1), a request was made from IC 1 to provide a copy of the patient’s plan of care. IC 1 stated, “Can you give me 10 minutes please, we don’t have it yet in our system”. A request was also made from IC 1 to provide copies of Patient 5’s SN visit notes but IC 1 stated the visiting nurse has not submitted any notes since the SOC. d. A review of Patient 8's admission record indicated a start of care date of 10/1/23, with a diagnosis that included type 2 diabetes mellitus, hypertension (high blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). On 10/13/23 at 1:35 p.m., a request was made from IC 1 to provide a copy of Patient 8’s POC. IC 1 stated the agency’s registered nurse have not generated a POC yet for Patient 8. IC 1 also stated there was no SN visit notes in the patient’s clinical records. On 10/13/23 at 1:50 p.m., during an interview and joint record review with the Director of Patient Care Services designee (DPCSD), the DPCSD stated the plan of care supposed to be completed within a week after the initial comprehensive assessment was done by the registered nurse. DPCSD further stated SN visit notes should have been submitted on the day the service was rendered per the agency’s policy. DPCSD stated and acknowledged the finding. A review of the agency's policy and procedure titled, "Care Planning Process", revised November 2022, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. a. A review of Patient 1's admission record indicated a start of care date (SOC) of 6/28/23, with a diagnosis that included hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period from 8/26.23 to 10/23/23, indicated that a skilled nurse (SN) was scheduled to visit once for the first week, then twice a week for two weeks, and then once a week for 6 weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate), and to teach patient and patient caregiver (PCG) on medication regimen and pain control measures. On 10/11/23 at 1 p.m., during a joint record review of Patient 1’s electronic heath record with the IC 1 (Intake Coordinator), indicated no documented evidence of a nursing visit note found in their computer system. During an interview with IC 1, when she was asked to print a copy, she stated she was not able to provide copies because the visiting nurse has not submitted the notes at this time. b. A review of Patient 2's admission record indicated a start of care date (SOC) of 9/15/23, with a diagnosis that included chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). A review of Patient 2's Home Health Certification and Plan of Care (POC) for the certification period from 9/15/23 to 11/13/23, indicated that a skilled nurse (SN) was scheduled to visit once for the first week, then twice a week for two weeks, and then once a week for 7 weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate), and to teach patient and patient caregiver (PCG) on medication regimen and pain control measures. On 10/11/23 at 1:20 p.m., during a joint record review of Patient 1’s electronic heath record with the IC 1 (Intake Coordinator), indicated no documented evidence of a nursing visit note found in their computer system. During an interview with IC 1, when she was asked to print a copy, she stated she was not able to provide copies because the visiting nurse has not submitted the notes at this time. c. A review of Patient 3's admission record indicated a start of care date of 9/30/23, with a diagnosis that included hypertension osteoarthritis ( occurs when flexible tissue at the ends of bone wears down). On 10/11/23 at 1:30 p.m., during a joint record review of Patient 1’s electronic heath record with the IC 1 (Intake Coordinator), indicated no documented evidence of a nursing visit note found in their computer system. During an interview with IC 1, when she was asked to print a copy, she stated she was not able to provide copies because the visiting nurse has not submitted the notes at this time. d. A review of Patient 9's admission record indicated a start of care date of 9/30/23, with a diagnosis that included hypertension ( a condition in which the force of the blood against the artery walls is too high). On 10/11/23 at 1:40 p.m., during a joint record review of Patient 1’s electronic heath record with the IC 1 (Intake Coordinator), indicated no documented evidence of a nursing visit note found in their computer system. During an interview with IC 1, when she was asked to print a copy, she stated she was not able to provide copies because the visiting nurse has not submitted the notes at this time.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to ensure patient care records were safeguarded for 9 of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure has the potential risk for these records not being protected and putting the patient's confidential information at risk for unauthorized use by unauthorized personnel. Findings: On 10/11/23 at 11:40 a.m., during an observation, the door to the storage room which was next to the entrance door of the agency was wide open. Inside the storage room, there were two large black cabinet with its door unlocked and wide open. Inside these cabinets were multiple folders and binders with patient names, and clinical records. There was no staff present in the room where the medical records were stored. On 10/13/23 at 12:45 p.m., during an observation, the door to the storage room was wide open, and the door of the two large black cabinets was unlocked and wide open where patient clinical records were stored. There was no staff present in the room. On 10/13/23, at 12:47 p.m., during an interview with the Director of Patient Care Services Designee (DPCSD), the DPCSD confirmed the medical records were un-attended and stated she will make sure the cabinets were locked as well as the door to the storage room to prevent unauthorized access of patient clinical records. A review of the agency's policy and procedure titled, "Safeguarding/Retrieval of Clinical/Service Record" revised November 2022, indicated the organization will safeguard the clinical/service record against loss, destruction, tampering, or unauthorized use through the development of processes, policies and procedures. The clinical/service record will be safeguarded in compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements. All physical patient clinical/service records will be maintained in locked, waterproof file cabinets in a record room.