Every finding on record at G&A Home Health Care Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation survey authorized by the Centers for Medicare and Medicaid Services, Region 9, conducted on 1/12/2021 through 1/22/2021. Representing the California Department of Public Health: Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 36459, Health Facilities Evaluator Nurse Complaint Intake Number: CA00720190 Current Census: 26 Unduplicated Admissions: 36 Sampled Size: 8

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 home health agency (HHA) failed, for two of eight sampled patients (Patient 1 and Patient 6), to ensure the information entered in the Outcome and Assessment Information Set (OASIS - used to collect and report assessment data) reflected patients' actual condition and treatment. This deficient practice has a potential to result in developing the care plans that do not meet the patients' needs. Findings: 1) A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 7/24/2020. The POC with the certification period, from 11/21/2020 to 1/19/2021, indicated Patient 1's diagnoses which included diabetes mellitus (DM - a group of diseases that affect how the body uses blood sugar) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated Patient 1 had a medication, Victoza (injectable medication used to help lower blood sugar) 0.6 milligrams (mg - unit of measurement), inject subcutaneously (under the skin) daily. A review of Patient 1's OASIS, dated 11/18/2020, under the section of "Endocrine/Hematology" did not indicate that Patient 1 was taking Victoza, the injectable medications, for DM. A further review of Patient 1's OASIS, under the section of "Medications" indicated that there were no injectable medications prescribed for Patient 1. During a concurrent interview and Patient 1's record review with the Director of Patient Care Services (DPCS) on 1/22/2021, at 2:10 p.m., the DPCS stated she is responsible to check the accuracy of the OASIS. The DPCS stated that the OASIS should have the accurate information of Patient 1. 2) A review of Patient 6's record indicated Patient 6's start of care date with the agency was 10/23/2020, with diagnoses which included hypertension (high blood pressure) and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe). A review of Patient 6's OASIS, dated 12/18/2020, indicated that the section of "Primary Diagnosis & Other Diagnoses" had no entry. A further review of the OASIS indicated that Patient 6 was diagnosed with coronavirus (COVID-19) (highly contagious respiratory disease caused by a virus that can spread from person to person) during the episode and it was reported to the physician. Patient 6 was quarantined for 14 days and received treatment as ordered. Patient 6 was tested COVID-19 negative on 12/10/2020. During an interview with Patient 6 on 1/22/2020, at 12:45 p.m., Patient 6 stated that he was never tested COVID-19 positive. During a concurrent interview and record review with DPCS on 1/22/2021, at 1:50 p.m., the DPCS stated that Patient 6 was never tested COVID-19 positive. The DCPS stated she was off work on quarantine on 12/18/2020. Although the 12/18/2020 OASIS indicated it was completed by the DPCS, the DPCS stated the Registered Nurse (RN 1) was the nurse who conducted and completed Patient 6's assessment. The DPCS stated she was not sure why her name and signature was on Patient 6's 12/18/2020 OASIS. A review of an undated agency's policy and procedures titled, "OASIS Information," indicated the encoded OASIS data will accurately reflect the patient's status at the time of assessment. The policy and procedures further indicated that accurate means that the OASIS data transmitted to CMS (Center for Medicare and Medicaid Services) is consistent with the current condition(s) of the patient.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to maintain a record of patients' complaints. This deficient practice has a potential to result in delaying to resolve problems and address patients' needs in a timely manner. Findings: During an interview with the Director of Patient Care Services (DPCS) on 1/22/2021, at 1 p.m., the DPCS stated the HHA did not keep a complaint log for patients' complaints. When requesting to review the HHA's policy for grievance, the DPCS stated the HHA did not have one at the moment.

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 review all the medications and update the medication profile with currently used medications for five of eight sampled patients (Patient 1, Patient 2, Patient 4, Patient 6 and Patient 7). This deficient practice has the potential to put the patients at risk for medication errors and adverse drug reactions. Findings: 1) A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 7/24/2020. The POC with the certification period, from 11/21/2020 to 1/19/2021, indicated Patient 1's diagnoses which included diabetes mellitus (DM - high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for one time a week for one week, two times a week for two weeks, and then one time a week for six weeks. The POC indicated SN to instruct and validate patient and caregiver regarding knowledge on new/current medication as to dosage, route, frequency and action/potential adverse reactions and compliance. On 1/14/2021, at 11:35 a.m., a joint home visit with Licensed Vocational Nurse 1 (LVN 1) was conducted at Patient 1's residence. A review of Patient 1's current medications during the home visit indicated that Patient 1 was taking Buspirone (used to treat anxiety disorder) 10 milligrams (mg - unit of measurement) tablet one tablet twice a day, Vascepa (used to help lower fats in the blood) 1 gram (gm - unit of measurement) two capsules twice a day, and Ferosul (used to treat or prevent low blood levels of iron) 325 mg one tablet twice a day. A review of Patient 1's Drug Regimen Review, provided by the agency, indicated that Patient 1 had an order for Buspirone 5 mg every day and an order for Vascepa 1 gm once a day. There was no documentation indicated that Patient 1 was taking Ferosul. During a concurrent interview with LVN 1 on 1/14/2021 during the joint home visit at Patient 1's residence, LVN 1 stated she did not check Patient 1's medications every visit. During an interview with the Director of Patient Care Services (DPCS) on 1/22/2021, at 5:10 p.m., the DPCS stated that SN should review the patient's medications every visit. 2) A review of Patient 2's POC indicated Patient 2's start of care date with the agency was 9/23/2020. The POC with the certification period, from 11/22/2020 to 1/20/2021, indicated Patient 2's diagnoses which included osteoarthritis (tissue at the ends of bones wears down) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks including SN to instruct and validate patient and caregiver regarding knowledge on new/current medication as to dosage, route, frequency and action/potential adverse reactions and compliance. On 1/14/2021, at 1:40 p.m., a joint home visit with Licensed Vocational Nurse 1 (LVN 1) was conducted at Patient 2's residence. A review of Patient 2's current medications during the home visit indicated that Patient 2 was taking Amlodipine Besylate (used to treat high blood pressure and chest pain) 5 mg one tablet daily. A review of Patient 2's Drug Regimen Review, provided by the agency, did not indicate that Patient 2 was taking Amlodipine Besylate. During a concurrent interview with LVN 1 on 1/14/2021 during the joint home visit at Patient 2's residence, LVN 1 stated she did not check Patient 2's medications every visit. 3) A review of Patient 4's POC indicated Patient 4's start of care date with the agency was 11/7/2019. The POC with the certification period, from 11/17/2020 to 1/15/2021, indicated Patient 4's primary diagnosis was Type II Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks and once a week for seven weeks. On 1/14/2021, at 2:45 p.m., a home visit was conducted at Patient 4's residence with Registered Nurse (RN 1). During a review of Patient 4's current medications, Patient 4 was taking Senna 8.6 mg one to two tablets as needed for constipation at night. A review of the medication profile indicated Patient 4 was taking Senna 8.6 mg one tablet daily. A review of the medication profile and POC indicated that Patient 4 was taking Zolpidem 5 mg daily. During a concurrent interview with Patient 4, Patient 4 stated she was taking Zolpidem at bedtime. During a concurrent interview with RN 1 during the home visit, RN 1 stated that the medications should be checked every visit to ensure the patient is taking the medications correctly. 4) A review of Patient 6's POC indicated Patient 6's start of care date with the agency was 10/23/2020. The POC with the certification period, from 12/22/2020 to 2/19/2021, indicated Patient 6's diagnoses which included hypertension (high blood pressure) and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breath). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. Patient 6's POC indicated that a SN to instruct and validate patient and caregiver regarding knowledge on new/current medication as to dosage, route, frequency and action/potential adverse reactions and compliance. On 1/19/2021, at 11:30 a.m., a joint home visit with the Director of Patient Care Services (DPCS) was conducted at Patient 6's residence. A review of Patient 6's current medication during the home visit indicated that Patient 6 was taking Promethazine-Codeine syrup (combination medication used to treat cold or allergy symptoms) one teaspoon every eight hours as needed and Albuterol Sulfate (used to treat wheezing and shortness of breath) 2.5 milligram (mg - unit of measurement)/ 3 milliter (ml - unit of measurement) solution to inhale content of one nebule (puff) every six hours as needed. A review of Patient 6's Drug Regimen Review, provided by the agency, indicated that Patient 6 had an order for Promethazine-Codeine syrup one to two teaspoons every six hours as needed, and an order for Albuterol Sulfate 2.5 mg/3 ml to inhale two puffs every four hours or as needed. During a concurrent interview with the DPCS on 1/19/2021 during the joint home visit at Patient 6's residence, the DPCS stated that she did not have the most updated medications list for Patient 6. 5) A review of Patient 7's POC indicated Patient 6's start of care date with the agency was 11/7/2020. The POC with the certification period, from 1/6/2021 to 3/6/2021, indicated Patient 7's diagnoses which included diabetes mellitus (DM - high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. Patient 7's POC indicated that a SN to instruct and validate patient and caregiver regarding knowledge on new/current medication as to dosage, route, frequency and action/potential adverse reactions and compliance. On 1/19/2021, at 10:01 a.m., a joint home visit with Licensed Vocational Nurse 1 (LVN 1) was conducted at Patient 7's residence. A review of Patient 7's current medications during the home visit indicated that Patient 7 was taking Acetaminophen (used to treat pain or relieve fever) 325 mg tablet one tablet twice a day as needed, Clonidine (used to lower blood pressure) 0.1 mg tablet one tablet twice a day as needed, and Drisdol (used in the treatment of hypoparathyroidism).one capsule every two weeks. A review of Patient 7's Drug Regimen Review, provided by the agency, indicated that Patient 7 had an order for Tylenol (Acetaminophen) 650 mg one tablet daily as needed, and an order for Clonidine 0.1 mg one tablet daily. There was no documentation found in the Drug Regimen Review, provided by the agency, that indicated Patient 7 was taking Drisdol. During a concurrent interview with LVN 1 on 1/19/2021 during the joint home visit at Patient 7's residence, LVN 1 stated that she did not check Patient 7's medications every visit. During an interview with the Director of Patient Care Services (DPCS) on 1/22/2021, at 5:10 p.m., the DPCS stated that SN should review the patient's medications every visit. A review of an undated policy & procedures titled, "Medication Profile," indicated the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician 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's (HHA) failed to ensure the Skilled Nurse (SN) assessed the patient's skin condition, for one of eight sampled patients (Patient 1). This deficient practice has a potential to result in delaying treatment for Patient 1 and delaying the development of a care plan that meet Patient 1's needs. Findings: A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 7/24/2020. The POC with the certification period, from 11/21/2020 to 1/19/2021, indicated Patient 1's diagnoses which included diabetes mellitus (DM - high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for one time a week for one week, two times a week for two weeks, and then one time a week for six weeks. The POC indicated that SN recertified the patient for comprehensive skilled nursing assessment, observation and evaluation of all body systems. In addition, Patient 1's POC indicated that Patient 1 had a new medication, Triamcinolone (used to treat a variety of skin conditions) ointment, 0.6 percent. The direction was applying to affected area (left chest) two times daily. A review of Patient 1's Outcome and Assessment Information Set (OASIS - used to collect and report assessment data), dated 11/18/2020, indicated that there was no problem in the integumentary (skin) status of Patient 1. A further review of the OASIS indicated that Patient 1 needed additional recertification per physician orders due to newfound rash and discomfort on the chest. A review of Patient 1's clinical notes, dated 11/21/2020, 11/23/2020, 11/26/2020, 12/2/2020, 12/5/2020, 12/10/2020, 12/18/2020, 12/24/2020, 12/31/2020 and 1/5/2021, indicated there was no documentation regarding the status of Patient 1's rash, but only indicated dryness under the integumentary section. During an interview with the Director of Patient Care Services (DPCS) on 1/22/2021, at 2:10 p.m., the DPCS stated that there should have been an assessment and documentation regarding Patient 1's rash. A request for the policy and procedures for skin assessment and management was initiated. However, the HHA did not provide the requested policy throughout the survey period. A review of an undated policy and procedures titled, "Care Planning Process," indicated that the clinicians will inform the patient's physician of any changes that suggest a need to alter the plan of care.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the physician reviewed the Plan of Care (POC), for five of eight sampled patients (Patient 1, Patient 2, Patient 4, Patient 5 and Patient 8), as evidenced by signing the POC. This deficient practice has a potential to result in medications and treatment errors that place patients at risk. Findings: 1) A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 7/24/2020. The POC with the certification period, from 11/21/2020 to 1/19/2021, indicated Patient 1's diagnoses which included diabetes mellitus (DM - high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for one time a week for one week, two times a week for two weeks, and then one time a week for six weeks. There was no physician's signature found on the POC. 2) A review of Patient 2's POC indicated Patient 2's start of care date with the agency was 9/23/2020. The POC with the certification period, from 11/22/2020 to 1/20/2021, indicated Patient 2's diagnoses which included osteoarthritis (tissue at the ends of bones wears down) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. There was no physician's signature found on the POC. 3) A review of Patient 4's POC indicated Patient 4's start of care date with the agency was 11/7/2019. The POC with the certification period, from 11/17/2020 to 1/15/2021, indicated Patient 4's primary diagnosis was Type II Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks and once a week for seven weeks. There was no physician's signature found on the POC. 4) A review of Patient 5's POC indicated Patient 5's start of care date with the agency was 11/6/2020. The POC with the certification period, from 11/6/2020 to 1/4/2021, indicated Patient 5's primary diagnosis was hypertensive heart disease (high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for once a week for the first week, twice a week for two weeks and then once a week for six weeks. There was no physician's signature found on the POC. 5) A review of Patient 8's POC indicated Patient 8's start of care date with the agency was 9/12/2020. The POC with the certification period, from 11/11/2020 to 1/9/2021, indicated Patient 8's diagnoses which included spinal stenosis (narrowing of spaces within the spine) and osteoarthritis (tissue at the ends of bones wears down). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks and then one time a week for seven weeks. There was no physician's signature found on the POC. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2021, at 4:05 p.m., the DPCS stated that plan of care should be signed by the physician. During an interview with the DPCS on 1/22/2021, at 3 p.m., the DPCS stated the POC should be signed by the physician to indicate approval of the orders and treatment. The DPCS also stated that this should be done as soon as possible. A review of an undated policy & procedures titled, "Care Planning Process," indicated the plan of care needs an approval & signature within 30 working days by the attending physician.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians 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 that patient care was coordinated with the primary physicians for four of eight sampled patients (Patient 1, Patient 2, Patient 6 and Patient 7). This deficient practice resulted in lacking communication between patients' primary physician and the referring physicians. This deficient practice has a potential to affect the effectiveness to meet patients' goals. Findings: 1) A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 7/24/2020. The POC with the certification period, from 11/21/2020 to 1/19/2021, indicated Patient 1's diagnoses which included diabetes mellitus (DM - high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for one time a week for one week, two times a week for two weeks, and then one time a week for six weeks. During an interview with Patient 1's primary physician on 1/22/2021, at 1:51 p.m., he stated that he did not refer Patient 1 to home health and that he did not know the referring physician whom referred Patient 1 to the home health agency. 2) A review of Patient 2's POC indicated Patient 2's start of care date with the agency was 9/23/2020. The POC with the certification period, from 11/22/2020 to 1/20/2021, indicated Patient 2's diagnoses which included osteoarthritis (tissue at the ends of bones wears down) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. During an interview with Patient 2's primary physician on 1/22/2021, at 8:30 a.m., he stated that he did not know that Patient 2 was receiving home health services. Patient 2's primary physician further stated that he did not know the referring physician whom referred Patient 2 to the home health agency. 3) A review of Patient 6's POC indicated Patient 6's start of care date with the agency was 10/23/2020. The POC with the certification period, from 12/22/2020 to 2/19/2021, indicated Patient 6's diagnoses which included hypertension (high blood pressure) and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breath). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. During an interview with Patient 6's primary physician on 1/22/2021, at 8:40 a.m., he stated that he did not know that Patient 6 was receiving home health services. Patient 6's primary physician further stated that he did not know the referring physician whom referred Patient 6 to the home health agency. 4) A review of Patient 7's POC indicated Patient 6's start of care date with the agency was 11/7/2020. The POC with the certification period, from 1/6/2021 to 3/6/2021, indicated Patient 7's diagnoses which included diabetes mellitus (DM - high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. During an interview with Patient 7's primary physician on 1/22/2021, at 8:55 a.m., she stated that she did not know that Patient 7 was receiving home health services. Patient 7's primary physician further stated that she did not know the referring physician whom referred Patient 7 to the home health agency. During an interview with the Director of Patient Care Services (DPCS) on 1/22/2021, at 2:10 p.m., she stated that the HHA does not contact the patients' primary physicians. A review of an undated policy and procedures titled, "Admission Criteria and Process," indicated that the organization will utilize referral information provided by the family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program. The policy and procedures further indicated that if the patient's physician does not make the request for service, he/she will be consulted prior to the evaluation visit and initiation of services.

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 interview and record review, the Home Health Agency ( (HHA) failed to educate regarding diabetic management as indicated in the plan of care for two of eight patients (Patient 3 and Patient 4). This failure had the potential to delay treatment and patients goals. Findings: 1. A review of Patient 3's clinical record indicated a start of care dated 10/22/2020 with a primary diagnosis of type II diabetes mellitus (a chronic disease characterized by high levels of sugar in the blood). A review of Patient 3's plan of care from 12/21/2020 to 2/18/2021 included an order for the skilled nurse (SN) to visit twice a week for two weeks and once a week for seven weeks. The plan of care indicated to document accurate blood sugar test results and teach diabetic management. 2. A review of Patient 4's clinical record indicated a start of care dated 11/7/19, with a primary diagnosis of type II diabetes mellitus. A review of Patient 4's plan of care from 11/17/2020 to 1/15/2021 included an order for the SN to visit twice a week for two weeks and once a week for seven weeks. The plan of care indicated for the SN to instruct patient on diabetic management. During an interview and a concurrent record review with the Director of Patient Care Services (DPCS), on 1/22/2021 at 1 p.m., Patient 3's and Patient 4's clinical notes did not have a blood sugar log in the clinical notes for the days the nurse did not conduct a home visit. There was no documentation of the patients and caregivers able to perform a return demonstration (when someone demonstrates what have just been taught) regarding blood sugar monitoring. The DPCS stated that the nurse should have documented the effectiveness of the return demonstration by the patient and caregiver. She stated the blood sugar levels should be assessed for the days the nurse is not there (at the patient's home) to evaluate if medications are keeping the blood sugar level stable. A review of the HHA's undated policy & procedure titled "Patient Education Process" indicated the clinician will assess, plan, implement, and evaluate the each patient and family/caregiver, as appropriate.

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 report to the Department, the licensing and certification agency, and the local health department three staff, who became positive for Coronavirus (COVID-19, a virus causing respiratory illness) in accordance with the facility's policy and procedure. A Licensed Vocational Nurse (LVN 1) exposed two of eight sampled patients (Patient 1 and Patient 8). This deficient practice had the potential to put the patients and staff at increased risk for infection. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/24/2020, with diagnoses which included diabetes mellitus (DM) (high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). A review of Patient 1's Clinical Note indicated that LVN 1 had visited the patient on 11/21/2020 from 7 a.m. to 7:45 a.m. A review of Patient 1's General Patient Communication, dated 11/21/2020, indicated that LVN 1 had tested positive for COVID-19, and that LVN 1 had conducted a skilled nurse visit (on 11/21/2020 from 7 a.m. to 7:45 a.m.) prior to LVN 1 testing positive and that Patient 1 was notified of the exposure to LVN 1 via a telephone call. b. A review of Patient 8's clinical record indicated a start of care date (SOC) of 9/12/2020, with diagnoses which included spinal stenosis (narrowing of spaces within the spine) and osteoarthritis (tissue at the ends of bones wears down) A review of Patient 8's Clinical Note indicated that LVN 1 had visited the patient on 11/21/2020 from 10 a.m. to 10:45 a.m. A review of Patient 8's General Patient Communication, dated 11/21/2020, indicated that LVN 1 had tested COVID-19 positive and that LVN 1 had conducted a skilled nurse visit (on 11/21/2020 from 10 a.m. to 10:45 a.m.) prior to LVN 1 testing positive and that Patient 8 was notified of the exposure to LVN 1 via a telephone call. A record review of the COVID-19 Contact Tracing indicated that 3 licensed staff members tested COVID-19 positive. The Director of Patient Care Services (DPCS) last saw a patient on 12/06/2020 and the DPCS tested COVID-19 positive on 12/10/2020. The DPCS returned to work 1/1/2021. Registered Nurse 1 (RN 1) last saw a patient on 12/28/2020 and RN 1 tested COVID-19 positive on 12/29/2020. RN 1 returned to work 1/5/2021. LVN 1 last saw Patient 1 and Patient 8 on 11/21/2020 and LVN 1 tested COVID-19 positive on 11/21/2020. LVN 1 returned to work 11/29/2020. The COVID-19 Contact Tracing further indicated that LVN 1 had contact with Patient 1 and Patient 8. During an interview with the DPCS, on 1/14/2021 at 2 p.m., she stated that there was a total of three COVID-19 positive staff including herself. The DPCS was asked if the cases had been reported to the Department, the licensing and certification agency, and to the local health department. The DPCS stated that the cases had not been reported because she thought the it (the positive test results) would be sent automatically from the lab. She confirmed that she failed to report the cases. A review of the HHA's policy and procedure, dated 3/24/20, titled, "Pandemic Infectious Disease" indicated any staff with COVID-19 should be reported to the Department of Public Health.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that a written patient care instructions for home health aide was prepared for one of eight patients (Patient 1). This deficient practice had the potential to result in a service not being given and miscommunication between healthcare providers. Findings: A review of Patient 1's clinical record indicated a start of care date (SOC) of 07/24/2020, with diagnoses which included diabetes mellitus (DM) (high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). A review of Patient 1's Doctor's Order, dated 11/23/2020, indicated that Patient 1 was re-certified for Certified Home Health Aide (CHHA) services for the certification period of 11/21/2020 to 01/21/2021. A review of Patient 1's clinical record indicated that there was CHHA weekly visit records, but no CHHA assignment (written patient care instruction) found. During an interview with Director of Patient Care Services (DPCS), on 1/20/2021, at 3:30 p.m., she stated there was no CHHA assignment and that CHHA only uses the weekly visit record and returns the record back to the agency. The DPCS stated that the HHA did not have a policy and procedure regarding having a CHHA assignment in writing. A review of the agency's policy and procedure titled, "Home Health Aide Supervisory Visits," undated, indicated that when an agency provides or arranges for home health aide services for a patient in comjuction with skilled nursing services, the services will be given in accordance with a written plan of treatment or plan of care and the case will be supervised by a registered nurse. The policy and procedure further indicated that the supervisor nurse will be responsible for providing written instructions for patient care.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that a supervisory visit for home health aide was conducted every 14 days for one of eight sampled patients (Patient 1). This deficient practice resulted in lack of oversight and had the potential to result in services not being given. Findings: A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/24/2020, with diagnoses which included diabetes mellitus (DM) (high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). A review of Patient 1's Doctor's Order dated 11/23/2020, indicated that Patient 1 was re-certified for Certified Home Health Aide (CHHA) services for the certification period of 11/21/2020 to 1/21/2021. A review of Patient 1's clinical record indicated that there was a CHHA supervisory visit conducted on 11/19/2020 and 1/04/2021. No other CHHA supervisory visit documentation found on the clinical record between 11/19/2020 to 1/04/2021. During an interview with Director of Patient Care Services (DPCS) on 1/22/2021 at 2:10 p.m., she stated CHHA supervisory visit for Patient 1was conducted via telephone and that supervisory visits are conducted once a month. Informed DPCS that CHHA supervisory visits should be conducted onsite every 14 days and she stated, "Is that new?" A review of the agency's policy and procedure titled "Home Health Aide Supervisory Visits," undated, indicated that if the patient receives skilled care, the registered nurse will make an onsite visit to the patient's home no less frequently than every two weeks.

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 interview and record review, the Home Health Agency (HHA) failed to ensure that the Licensed Vocational Nurse (LVN 1) was qualified per the agency's job description. This deficient practice had the potential to compromise the quality of the services provided to the patients. Findings: A review of LVN 1's employee records on 1/20/2020, indicated that LVN was hired at the HHA on 4/22/2020 and that her LVN license was issued on 9/16/19. During an interview with Director of Patient Care Services (DPCS), on 1/22/2021 at 2:40 p.m., she stated that she is responsible for the hiring of the employees of the HHA and that she was the one who hired LVN 1. DPCS stated she did not know what was on the HHA's LVN job description regarding nursing experience. A review of the agency's job description titled "Licensed Practical/Vocational Nurse" undated, indicated that one of the position qualifications includes three years nursing experience.