Every finding on record at Genus Home Care of San Bernardino

The following reflects the findings of the California Department of Public Health during an Emergency Preparedness survey conducted on June 15, 2026, through June 18 , 2026 Census: 38 Unduplicated Admissions: Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All Conditions of Participation were met One (1) standard deficiency was issued

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of seven staff members was knowledgeable about the location of the facility’s designated alternate meeting location in case of emergencies. This failure had the potential for a delay in the overall facility communication and coordination of services for all 38 vulnerable patients at risk who received care from the facility. Findings: During an interview on June 16, 2026, at 10:15 AM, with Licensed Vocational Nurse (LVN 1), at Patient 1’s home, LVN 1 stated that she does not know where the facility’s alternate emergency meeting location was. LVN 1 further stated that she has not been educated or done in-service training (provided to employees while on job) regarding emergency preparedness. During an Interview on February 18, 2026, at 12:30 PM, with the Director of Patient Care services (DPCS), the DPCS stated that, “All staff should have been educated and in-serviced on emergency preparedness, LVN should know the designated and alternate meeting location in case of emergency”. During a follow up concurrent interview and record review on February 18, 2026, at 1:15 PM, with the DPCS, the facility’s document titled, “EMERGENCY PEPAREDNESS / DISASTER RECALL TREE”, undated, was reviewed, and “In-Service Sign-In-Sheet for Emergency Preparedness Training,” (Sign in sheet), dated from May 2025 to June 2026, was reviewed. The “EMERGENCY PEPAREDNESS / DISASTER RECALL TREE” indicated, “…IN THE EVENT THAT THE AGENCY OR ITS SURROUNDING OBATAIN ANY NATURAL DISASTER OR FIRE. THE OFFFICE STAFF WILL MEET WITH FIELD STAFF TO RECONCILE ALL INFORMATION AND PATIENT’S CONDITION IN THE: 1ST Command Post: Parking Lot of County Building at 157 W. 5th Street, San Bernadino, CA 92401, 2nd Command Post: Administrator’s Residence: 1476 W. 9th Street Upland, CA 91786…” The Sign in sheet did not indicate LVN 1 completed the training. The DPCS verified and confirmed that LVN 1 has not completed facility’s in-service emergency preparedness training, and this failure has the potential to place vulnerable patients at risk for delays in communication and coordination of services.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on June 15, 2026, through June 18 , 2026 Census: 38 Unduplicated Admissions: Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All Conditions of Participation were met One (1) standard deficiency was issued

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure personal health information was kept confidential for one of three sampled patients (Patient 1) when Licensed Vocational Nurse (LVN 1) received and sent Patient 1’s clinical records using her personal cell phone. This failure resulted in Patient 1’s personal health information being put at risk by not keeping health records confidential, and using personal equipment not being monitored and secured by the agency. Findings: A review of Patient 1’s face sheet (contains demographic and medical information), undated, indicated Patient 1’s start of care date of December 8, 2015, with a certification period of April 14, 2026, to June 12, 2026. Patient 1 had diagnosis that included spastic quadriplegic cerebral palsy (cerebral palsy-CP-a group of disorders affecting a person’s ability to move, maintain balance, and posture, the most severe form of CP, affecting muscle control in all four limbs, the trunk, and the face, caused by brain damage before or around birth). During a home visit observation on June 16, 2026, at 10:00 AM, with LVN1, LVN 1 was sending Patient 1’s confidential personal medical information on her personal cell phone. During a subsequent interview with LVN1, LVN1 verified and confirmed she uses her personal cell phone to send and receive Patient’s confidential information to the agency without using a secure app (a shortened term for “application” or “application program”), LVN 1, further stated that the agency has provided secure app to send or receive patients’ confidential information, but she used her personal cell phone to text patients confidential Information. During an interview on June 18, 2026, at 10:30 AM with the Director of Patient Care Services (DPCS), the DPCS confirmed that the agency has secure app to send or receive patient’s confidential information, but LVN 1 used her personal cell phones to send and receive patient confidential information. During a concurrent interview and record review on June 18, 2026, at 11:30 AM, with the DPCS, the facility’s policy and procedure (P&P) titled, “CONFIDENTIALITY OF INFORMATION POLICY”, dated December 2007, was reviewed. The P&P indicated, “POLICY STATEMENT- it will be the policy of this Agency to insure the confidentiality, security, and integrity of patient and Agency information by all staff members…15. The Agency will assure conformance with current acceptable professional standards and follow state laws that may be more prescriptive…” The DPCS stated LVN 1 did not follow the agency policy for “confidentiality of information policy”.

The following reflects the findings of the California Department of Public Health during an Emergency Preparedness survey conducted June 5, 2023, through June 8, 2023. Representing the Department: Surveyors: 46119, 45431 Census: 23 Unduplicated Admissions: 1 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All conditions of participation were met

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the year 2022. This failure had the potential to put patients at risk when the agency was not prepared to respond to the hazards most likely to occur in the community. During an interview on June 8,2023, at 2:14 PM with the Administrator (ADM), ADM stated they collaborated with the San Bernardino and Riverside County, however ADM was unable to show documented evidence in the EOP how the agency will collaborate with other entities within the community to coordinate a response to an emergency. During a review of the agency’s Emergency Preparedness Plan (EOP), undated, the EOP did not indicate the procedure on how the agency will collaborate with local, regional, state, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to include in their Emergency Preparedness Plan the process of informing emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the year 2022. This failure had the potential to put patients at risk when the when the agency was not prepared to work with the emergency management office during an emergency or disaster. During an interview on June 8,2023, at 2:34 PM with the Administrator (ADM), the ADM stated the agency will inform the emergency preparedness officials by using the organizational or incident objective list form attached to the EOP, however, ADM was unable to show documented evidence of the agency’s procedure for informing state and local emergency preparedness officials about patients in need of evacuation and the required needs of the patients during the evacuation process. During a review of the agency’s Emergency Preparedness Plan (EOP), undated, the EOP did not indicate the process on how the agency will inform the emergency preparedness officials about patients in need of evacuation and the required needs of the patients during the evacuation process.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted June 5, 2023 to June 8,2023. Representing the Department: Surveyors: 46119, 45431 Census: 23 Unduplicated Admissions: 1 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All conditions of participation were met

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a verbal order from the physician was reflected in the medical record for one of seven sampled patients (Patient 4). This failure had the potential to cause Patient 4 to not receive services ordered by the physician. A review of Patient 4’s plan of care (a document which contains physician’s orders and provides direction on the type of clinical care a patient needs), indicated a start of care date of November 18, 2022, with a certification period of May 17, 2023, to July 15, 2023. Patient 4 had diagnoses which included hypoxic ischemic encephalopathy (brain damage caused by lack of oxygen for a prolonged period of time). A review of Patient 4’s plan of care dated May 17, 2023, to July 15, 2023, indicated Patient 4 had physician orders to receive “…LVN [licensed vocational nurse] care of 164-172 hrs/month [hours per month] …” A review of Patient 4’s scheduled visit notes was conducted on June 6, 2023. There was no documented evidence Patient 4 had been seen by an LVN since the beginning of the certification period on May 17, 2023. During an interview with the Administrator (ADMIN) on June 6, 2023, at 4:04 PM, the ADMIN stated the LVN care had been put on hold by the physician, until an LVN was available to provide regularly scheduled visits for Patient 4. The ADMIN verified there was no evidence of the verbal order in the medical record, and there should have been. The ADMIN stated her expectations were for the nurse who obtained the order from the physician, to document the order in the medical record. During a concurrent interview and record review with the ADMIN on June 8, 2023, at 11:34 AM, the agency’s policy and procedure (P&P) titled, “Communication with a Physician Policy”, revised December 2007, was reviewed. The P&P indicated “…2. Staff members communication with a patient’s physician will document the communication via one or more of the following forms which are filed in the patient’s clinical record:…b. Verbal Order Form…7…An RN will make the necessary revisions to the Plan of Care based on verbal orders…”. The ADMIN stated they did not follow their policy.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to inform the physician when two medications: Ursodiol (a medication used to treat liver conditions) and Carafate (a topical drug used in treating various skin wounds) were not available during the home visits for one of three sampled patients. (Patient 3). This failure had the potential to cause Patient 3 not to receive the full benefits of the medications. 1. During a review of patient 3’s plan of care (a document which contains physician’s orders and provides direction on the type of clinical care a patient needs), indicated a start of care date of July 20,2016 with a certification period of April 15,2023 to June 13,2023. Patient 3 had diagnoses which included multiple congenital malformation (An often-inherited medical condition that occurs at or before birth) including intestinal malabsorption (A condition that prevents absorption of nutrients through the small intestine). During a review of patient 3’s plan of care dated April 15,2023 to June 13.2023, indicated Patient 3 had physician order for, “Ursodiol 60mg (milligram)/ml (milliliters) 0.628 ml (37.68mg) GT (gastrostomy tube) three times daily”. During a concurrent interview and record review, on June 6,2023, at 3:53 PM, with Licensed Vocational Nurse (LVN3), “Patient Medication Profile” dated April 15,2023 to June 13,2023 was reviewed. The “Patient Medication Profile” indicated patient should be receiving Ursodiol (medication used to dissolve gallstone) three times a day, however LVN3 stated this medication has not been given to the patient since June 1, 2023, because the medication was unavailable. LVN3 further stated she did not inform the RN or the physician about this change. During a review of patient 3’s “Medication/Treatment Record”, dated May 28, 2023, to June 3,2023, indicated Ursodiol was not administered from June 1, 2023, to June 7,2023. 2. During a review of patient 3’s plan of care dated April 15,2023 to June 13.2023, indicated Patient 3 had physician order for, “Carafate 100mg/ml 10 ml to GT site Topical three times a day”. During a concurrent interview and record review on June 6,2023 at 3:55 PM, with LVN3, “Patient Medication Profile” dated April 15,2023 to June 13,2023 was reviewed. The “Patient Medication Profile” indicated patient should be receiving Carafate ( a topical drug used in treating various skin wounds) 100mg/ml to GT site three times a day however LVN3 stated this medication has not been given to the patient since June 1, 2023, because the medication was unavailable. LVN3 further stated she did not inform the RN or the physician about this change. During an interview on June 7, 2023, at 3:53PM, with Acting Director of Patient Care Services (ADPCS), ADPCS stated the process if medication is unavailable, had missed doses or changes in treatment, is for the LVN or Registered Nurse (RN) to notify the physician. ADPCS stated the LVN, or RN cannot change or discontinue any medication without a physician’s order. ADPS further stated the LVN, and RN did not follow the process when they did not notify the physician of the missed doses. During a review of agency’s policy, “Administration of Medication Policy”, dated December 2007, the policy indicated, “…When there is a discrepancy in the medications found in the home… a nurse will contact the physician as soon as possible to verify the correct medication regimen”.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to use quality indicator (are standardized, evidence-based measures of health care data that can be used to measure and track the agency’s clinical performance and outcomes) data from OASIS (Outcome and Assessment Information Set), from January 1, 2022, to December 31, 2022, in a universe of 23 patients. This failure had the potential for the agency to miss statistically significant data from OASIS reports and fail to identify patient population trends. During a review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder, for year 2022 (January 1, 2022, to December 31, 2022), the QAPI binder did not indicate documented evidence of any quality indicators. During a review of the QAPI binder, undated, the QAPI binder did not indicate documented evidence to show quality indicators from the OASIS reports (The instrument/data collection tool used to collect and report assessment data by home health agencies) had been chosen for the period of January 1, 2022, to December 31, 2022. During an interview on June 8,2023 at 4:40 PM with the Administrator (ADM), ADM failed to show documented evidence that the agency used data from the OASIS reports to choose their quality indicators and stated, “We don’t have it.” During a review of the agency’s policy and procedure, “Quality Management Committee Policy” dated December 2007, did not indicate the process or procedures for the agency’s QAPI program. ADM stated this is the policy they use for their QAPI program.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to conduct and document performance improvement activities the agency had undertaken, from January 1, 2022, to December 31, 2022, in a universe of 23 patients. This failure had the potential to cause the agency to provide inferior care and services to its patients. During a review of the agency’s QAPI binder, for year 2022 (January 1, 2022, to December 31, 2022), the QAPI binder did not indicate any documented evidence that the agency had conducted process improvement activities for the year January 1, 2022, to December 31, 2022. During an interview on June 8, 2023, at 4:30 PM with the Administrator (ADM), ADM stated the agency has conducted performance improvement activities for the year 2022 however ADM is unable to show documented evidence of the performance activities undertaken. ADM stating, “We don’t have it.” During a review of the agency’s policy and procedure, “Quality Management Committee Policy” dated December 2007, did not indicate the process or procedures for the agency’s QAPI program. ADM stated this is the policy they use for their QAPI program.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to conduct performance improvement activities, therefore did not identify adverse patient events, track and analyze causes and implement corrective actions from January 1, 2022, to December 31, 2022, in a universe of 23 patients This failure had the potential to cause problems in health outcomes, patient safety and the quality of care. During a review of the QAPI binder for year 2022 (January 1, 2022, to December 31, 2022), the QAPI binder did not indicate documented evidence that the agency had conducted process improvement activities thus did not identify adverse patient events, track analyze cause and implement corrective actions. During an interview on June 8, 2023, at 4:30 PM with the Administrator (ADM), ADM stated the agency has conducted performance improvement activities for the year 2022 however ADM is unable to show documented evidence of the performance activities undertaken. ADM stating, “We don’t have it.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to conduct and document performance improvement projects (PIP - a temporary or short-term plan designed to improve a process and resulting in improved performance of an agency.) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, from January 1, 2022, to December 31, 2022, in a universe of 23 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care to go unaddressed and continue. A review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder was conducted for the year 2022 (January 1, 2022, to December 31, 2022). There was no documented evidence to show performance improvement projects had been initiated, were in process had been completed for the 12 months (January 1, 2022, to December 31, 2022) reviewed. During a concurrent record review and interview, on June 8, 2023, at 5:30 PM, with the Administrator (ADM) the contents of the QAPI binder were reviewed. The ADM stated she was responsible for the QAPI program. ADM stated the agency has conducted performance improvement activities for the year 2022 however she is unable to show documented evidence of the performance activities undertaken. ADM stated, “We don’t have it.” During a review of the agency’s policy and procedure, “Quality Management Committee Policy” dated December 2007, did not indicate the process or procedures for the agency’s QAPI program. ADM stated this is the policy they use for their QAPI program.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency’s Governing Body (GB) failed to provide oversight for its Quality Assessment and Performance Improvement (QAPI) Program from January 1, 2022, to December 31, 2023, in a universe of 23 patients when: The QAPI Program failed to use quality indicator (are standardized, evidence-based measures of health care data that can be used to measure and track the agency’s clinical performance and outcomes) data from OASIS (Outcome and Assessment Information Set), from January 1, 2022, to December 31, 2022, in a universe of 23 patients. The QAPI Program failed to conduct and document performance improvement activities the agency had undertaken, from January 1, 2022, to December 31, 2022, in a universe of 23 patients. The QAPI Program failed to conduct performance improvement activities, therefore did not identify adverse patient events, track and analyze causes and implement corrective actions from January 1, 2022, to December 31, 2022, in a universe of 23 patients. The agency failed to conduct and document performance improvement projects (PIP - a temporary or short-term plan designed to improve a process and resulting in improved performance of an agency.) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, from January 1, 2022, to December 31, 2022, in a universe of 23 patients. The Governing Body failed to approve the frequency and detail of the QAPI program’s data collection for the year 2022. This failure had the potential to cause the agency to provide inferior care and services to its patients. During a review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder, for 2022 (January 1, 2022, to December 31, 2022), the QAPI binder did not indicate documented evidence of any quality indicators. During a review of the QAPI binder, for 2022 (January 1, 2022, to December 31, 2022), the QAPI binder did not indicate documented evidence to show quality indicators from the OASIS reports (The instrument/data collection tool used to collect and report assessment data by home health agencies) had been chosen for the period of January 1, 2022, to December 31, 2022. During an interview on June 8,2023 at 4:40 PM with the Administrator (ADM), ADM failed to show documented evidence that the agency used data from the OASIS reports to choose their quality indicators and stated, “We don’t hav\\ 2. During a review of the agency’s QAPI binder, for 2022 (January 1, 2022, to December 31, 2022), the QAPI binder did not indicate any documented evidence that the agency had conducted process improvement activities for the year January 1, 2022, to December 31, 2022. During an interview on June 8, 2023, at 4:30 PM with the Administrator (ADM), ADM stated the agency has conducted performance improvement activities for the year 2022 however she is unable to show documented evicence of the performance activities undertaken. ADM stating, “We don’t have it. 3. During a review of the QAPI binder for year 2022, the QAPI binder did not indicate documented evidence that the agency had conducted process improvement activities thus did not identify adverse patient events, track analyze cause and implement corrective actions. During an interview on June 8, 2023, at 4:30 PM with the Administrator (ADM), ADM stated the agency has conducted performance improvement activities for the year 2022 however she is unable to show documented evidence of the performance activities undertaken. ADM stating, “We don’t have it.” 4. A review of the agency’s (QAPI) binder was conducted for the year 2022 (January 1, 2022, to December 31, 2022). There was no documented evidence to show performance improvement projects had been initiated, were in process had been completed for the 12 months (January 1, 2022, to December 31, 2022) reviewed. During a concurrent record review and interview, on June 8, 2023, at 5:30 PM, with the Administrator (ADM) the contents of the QAPI binder were reviewed. The ADM stated she was responsible for the QAPI program. ADM stated the agency has conducted performance improvement activities for the year 2022 however ADM is unable to show documented evidence of the performance activities undertaken. ADM stated, “We don’t have it.” 5. During a review of the agency’s QAPI binder for the year 2022 (January 1, 2022, to December 31, 2022), QAPI binder did not indicate documented evidence of that the QAPI Committee had provided the details and frequency of data collection to the GB for review and approval. During a review of the agency’s QAPI binder for the year 2022 (January 1, 2022, to December 31, 2022), review of the agency’s QAPI binder did not indicate evidence of documentation that the GB approved the frequency and detail of the QAPI program’s data collection for the year 2022. During a concurrent interview and record review on June 8,2023 at 4:30 PM with ADM, “Minutes of Annual Meeting of Board of Directors of Genus Home Care, Inc. of San Bernardino” date 01/06/2022 was reviewed. The agency document did not indicate GB’s approval of the QAPI program’s data collection for 2022. ADM stated they don’t talk about the QAPI program on the Board of Directors meeting, instead they conduct a different meeting to talk about the QAPI program. However, ADM was unable to show documented evidence of the meeting. During a review of the agency’s policy and procedure, “Quality Management Committee Policy” dated December 2007, did not indicate the process or procedures for the agency’s QAPI program. ADM stated this is the policy they use for their QAPI program.

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 observation, interview and record review, the agency failed to maintain a clean equipment when dirt and grime was observed on the feeding pump during the home visits of one of three sampled patients (Patient 3). This failure had potential to attract microorganism carrying pest that might cause infection to an already compromised Patient 3. A review of patient 3’s plan of care (a document which contains physician’s orders and provides direction on the type of clinical care a patient needs), indicated a start of care date of July 20,2016 with a certification period of April 15,2023 to June 13,2023. Patient 3 had diagnoses which included multiple congenital malformation (An often-inherited medical condition that occurs at or before birth) including intestinal malabsorption (A condition that prevents absorption of nutrients through the small intestine). A review of patient 3’s plan of care dated April 15,2023 to June 13.2023, indicated Patient 3 had physician orders to receive tube feeding, “Neocate Jr (a hypoallergenic formula specifically designed to address the growing nutritional and lifestyle needs of toddlers and older children) 47ml (milliliter) /hr. x 16 hrs. via GT (gastrostomy tube)”. During an observation on June 6,2023 at 3:37 PM, in patient’s residence, feeding pump was very dirty, dusty, and with grime on the grooves. The pump’s screen was also observed to be dusty, dirty and had sticky old dripping of feeding. During an interview on June 6,2023 at 3:55 PM with the Licensed Vocational Nurse, (LVN3), LVN3 stated the feeding pump was dirty and should have been cleaned by her every visit. During an interview on June 7, 20233 at 3:53 PM, with Acting Director of Patient Care Services (ADPCS) stated it is the LVN’s responsibility to maintain the medical equipment’s clean. ADPCS stated her expectation from the LVNs is to wipe them once a day, weekly or PRN. ADPCS further stated, the LVN did not follow the process of not keeping the equipment clean. During a review of the agency’s policy, “Pediatric Policies and Procedures: Gastrostomy Tube Feeding Procedure and Aspiration Precautions”, dated 04/10/2017, it indicated, “Care of the pump and feeding bag…Wipe down the feeding pump and IV pole daily and PRN spills”.

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 agency failed to ensure the medical record contained required items for one of seven sampled patients (Patient 5) when three Licensed Vocational Nurse (LVN) visit notes were not completed. This failure had the potential to cause clinical staff reviewing the medical record to make assessments and decisions based on incomplete information. A review of Patient 5’s plan of care (a document which contains physician’s orders and provides direction on the type of clinical care a patient needs), indicated a start of care date of April 5, 2022, with a certification period of March 31, 2023, to May 29, 2023. Patient 5 had diagnoses which included cerebral palsy (a brain disorder that affects a person's ability to move and maintain balance and posture). A review of Patient 5’s plan of care dated March 31, 2023, to May 29, 2023, indicated the patient had physician orders to receive “…LVN care of 100-136 hours per month…” A review of Patient 5’s LVN visit notes was conducted. There was no evidence to show the LVN had completed notes for the visits provided to the patient on the following dates: a. April 15, 2023 b. April 22, 2023 c. April 27, 2023 During an interview with the Administrator (ADMIN) on June 8, 2023, at 11:34 AM, the ADMIN stated her expectations were for the notes from nursing staff to be in the patient’s medical record within 72 hours, or the following Monday, after the visit was provided. The ADM verified the notes for April 15, 22 and 27, 2023 were not completed, and they should have been. A review of the agency’s policy and procedure (P&P) titled, “Nurse’s Notes Submission Policy”, revised December 2007, indicated, “…1) All nurses will submit their weekly nurses notes as follows: a) Every 72 hours, no later than Monday by 12 noon for the preceding week…d) All nurses will submit nurse’s notes that are complete…”