Every finding on record at Gfk Services, Inc.

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION Surveys. The survey team entered the home health agency on 6/18/26 at 0915 hours. The home health agency identified the census as 25. The survey sample size was 7. GLOSSARY AND DEFINITIONS: DPCS: Director of Patient Care Services P&P: Policies and Procedure

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 ensure the emergency preparedness plan included the process for collaboration with the tribal, regional, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This failure created the potential risk of not providing the necessary care and services to the patients of the HHA during emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 6/25/26, and showed the plan did not include a process for collaboration with the tribal, regional, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.

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 ensure the emergency preparedness P&Ps included the procedures to inform the State and local emergency preparedness officials about the 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 failure created the risk of not providing the necessary care and services to the patients during an emergency. Findings: Review of the agency’s emergency preparedness P&P titled Emergency Management Policy revised 9/17/20, was initiated on 6/25/26. The emergency preparedness P&P failed to show the procedures to inform the State and local emergency preparedness officials about 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. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s emergency preparedness P&P addressed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This failure had the potential for patient’s confidential information not to be protected. Findings: Review of the agency’s P&P on emergency preparedness was initiated on 6/25/26. The Emergency Plan did not address the system of medical documentation that preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency communication plan included a primary and alternate means of communication with the Federal, State, tribal, and regional emergency management agencies. This failure had the potential for not being able to contact or request assistance in emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 6/25/26. The communication plan failed to include the primary and alternate means of communication with the Federal, State, tribal and regional emergency management agencies. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included a method for sharing information and medical documentation for the patients under the HHA’s care, as necessary, with other health providers to maintain the continuity of care. This failure created the risk of not providing the necessary care and services to patients during emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 6/25/26. The emergency preparedness communication plan did not include a method for sharing the information and medical documentation for the patients under the HHA’s care, as necessary, with other health providers to maintain the continuity of care. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to conduct exercises to test the emergency plan annually for the years of 2024 and 2025. This failure created the risk of the staff not knowing what to do in case of emergency. Findings: Review of the agency’s emergency preparedness testing program was conducted on 6/25/26 and showed no documented evidence the agency participated in a full-scale exercise that is community based or facility based functional exercises that may include mock disaster drills for the years 2024 and 2025. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.

The following reflects the findings of the California Department of Public Health during the concurrent Recertification and Emergency Preparedness Surveys. The survey team entered the HHA on 6/19/26 at 0915 hours. The HHA identified the census as 25. The survey sample size was 7. GLOSSARY AND DEFINITIONS: BM: bowel movement BP: Blood pressure bpm: beats per minute CEO: Chief Executive Officer CHHA: Certified Home Health Aide DBP: Diastolic Blood Pressure DPCS: Director of Patient Care Services gm: gram(s) GT: Gastrostomy tube (G-tube) a medical device inserted through the abdomen directly into the stomach. HHA: Home Health Agency hr: hour IV: Intravenous LVN: Licensed Vocational Nurse mg: milligram(s) ml: milliliter(s) mmHg: millimeter(s) of mercury OASIS: Outcome and Assessment Information Set P&P: Policy and Procedure PCG: Patient Caregiver POC: Plan of Care PRN: as needed RN: Registered Nurse SBP: Systolic blood pressure SN: Skilled Nurse/Nursing SOC: Start of Care TB: Tuberculosis (a contagious lung disease)

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OASIS data were transmitted within 30 days of completing the OASIS data sets. This failure had the potential for not reporting and coordinating the patient care assessment timely for the patients receiving care and services at the agency. Findings: Review of the Agency Error Summary Reports from 6/1/25 to 5/31/26, was initiated on 6/23/26. The Agency Error Summary Report for 6/1/25 to 5/31/26, showed 10 OASIS data sets were submitted more than 30 days from the assessment completion date. On 6/23/26 at 0810 hours, an interview and concurrent agency document review were conducted with the CEO and Nursing Coordinator. The CEO confirmed the 10 OASIS data sets were submitted late.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the SOC date for three of seven sampled patients (Patients 2, 6, and 7). This failure had the potential for not identifying and addressing the care needs for these patients timely. Findings: #1. Review of Patient 6's clinical record was initiated on 6/24/26. The clinical record showed the SOC was 1/28/26 The patient was certified for home health services during the certification periods from 3/29/26 to 5/27/26 and 5/28/26 to 7/26/26. Review of the OASIS E1 Start of Care Assessment dated 1/28/25 showed the Nursing Coordinator had performed a comprehensive assessment. The assessment included the section for the Emergency Disaster /Disaster code; Advance Directives: Living Will, Power of Attorney, Patient Legal Representative, Patient chosen caregiver, and scope they will perform, inform patient and their right in advance of providing hands on care or patient education; DNR status; Allergies; Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. On 6/26/26 at 1013 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Comprehensive Patient Assessment revised 1/9/26, showed a thorough, well organized, comprehensive and accurate assessment, consistent with the patients immediate needs will be completed for all patients in a timely manner, but no later than five calendar days after start of care. For example: 1.Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the OASIS SOC Comprehensive Assessment dated 6/18/20, failed to show documented evidence the following were completed: -Vitals assessed -Structural barriers -Safety hazards -Sanitation hazards -Hearing condition -Nasal condition -Pharyngeal (anything related to the throat) condition -Mouth condition -Pain status -Braden pressure ulcer risk -Psychological/Social -Blood sugar -Endocrine/Diabetes management -Fall risk assessment -Orders -Goals -Patient information and input -Care Plan information -Skilled intervention (procedure and teaching) On 6/26/26 at 1115 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator had provided additional documentation, however, the abovementioned components of the OASIS SOC Comprehensive Assessment were left blank. The Nursing Coordinator confirmed the findings. 2. Review of Patient 7’s clinical record was initiated on 6/23/26. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services for 30 certification periods including certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. Review of the OASIS SOC Comprehensive Assessment dated 8/20/21, failed to show documented evidence the following were completed: -Vitals assessed -Structural barriers -Safety hazards -Sanitation hazards -Hearing condition -Nasal condition -Pharyngeal condition -Mouth condition -Musculoskeletal -Pain status -Integumentary -Braden pressure ulcer risk -Respiratory status -Elimination status -Frequency of disruptive behavior -Psychological/Social -Blood sugar -Endocrine/Diabetes management -Fall risk assessment -Patient information and input -Care Plan information -Spiritual/cultural needs -Nutritional status -Homebound reasons -Criteria for evaluating a patient’s risk following a disaster -Skilled intervention (procedure and teaching) On 6/26/26 at 1054 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator had provided additional documentation, however, the abovementioned components of the OASIS SOC Comprehensive Assessment were left blank. The Nursing Coordinator confirmed the findings.

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 agency failed to ensure the medication profiles were updated to reflect the current medications and include specific indications and parameters for its use for four of seven sampled patients (Patients 1, 2, 5, and 7). This failure had the potential for the patients not to receive the appropriate care and necessary services and negatively affect the patients' well-being. Findings: #. Review of Patient 5's clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. The Medication Profile from 5/1/26 to 6/29/26 showed the patient was on metoprolol tartrate (beta blocker) 25 mg GT give 0.5 mg tablet hold if HR less than 65 or SBP less than 100 and magnesium gluconate (supplement) 550 mg oral tablet GT give one tablet daily. A joint home visit with LVN 1 was conducted on 6/23/26 at 0815 hours, to the Patient 5’s home. However, the instructions in metoprolol tartrate bubble pack showed to take 1/2 tablet by mouth every morning and before bedtime instead of daily as written in the medication profile. In addition, the dosage for magnesium gluconate was 500 mg tablet instead of 550 mg as written in the medication profile. On 6/23/26 at 1038 hours, an interview was conducted with the PCG 1. PCG 1 was asked about the frequency of metoprolol. PCG 1 replied, the medication was given 1/2 tablet in AM and PM. LVN 1 was also asked if the medication profile was updated. LVN 1 did not respond. LVN 1 was informed of the findings. On 6/26/26 at 1249 hours the findings were shared with The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Medication Profile (undated) showed the medication profile shall include all prescription and nonprescription including regularly scheduled medications and those taken intermittently or as needed. The profile will be reviewed and updated as needed to reflect current medications the patient is taking. 1.Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. The Medication Profile for Patient 1 for the certification period from 5/23/26 to 7/21/26 showed Senna-Time (laxative) 8.6 mg tablet administered via GT, give two tablets daily as needed for constipation. May increase up to four tablets two times a day as needed for severe constipation. However, the bottled medication at the patient’s home showed Senna-Time (laxative) 8.6 mg tablet administered via GT, give two tablets daily as needed for constipation. May increase up to four tablets two times a day as needed for severe constipation. Hold if having loose stools. Do not exceed eight tablets in 24 hours. The Medication Profile was not updated to show the additional indications of the above medication. Furthermore, the following medications were also included in the Medication Profile for Patient 1 for the certification period from 5/23/26 to 7/21/26: -Nystop (fungal skin infection) 100,000 unit/gm topical powder, applied to skin surface/left under arm as needed. -hydrocortisone (treatment for various skin conditions) 2.5 percent topical ointment, applied to affected area two times a day as needed (for penile foreskin swelling related to allergy to foley catheter). -lactulose (laxative) 10 gm in 15 ml oral solution administered via GT, give 30 ml two times a day as needed for severe constipation. However, the above medications were not in the patient’s home. A joint visit with LVN 2 was conducted on 6/19/26 at 1430 hours, to Patient 1’s home. LVN 2 stated the medications were checked on the day of the home visit and were discontinued. In addition, the medications had not been administered for several months and were already expired. The LVN confirmed the medication profile was not updated. An interview was conducted with the CEO and Nursing Coordinator on 6/23/26 at 0810 hours. The Nursing Coordinator stated the medications were reviewed on the day of the visit. The medications were not in use for several months. The Nursing Coordinator was asked how often the nurses conduct medication reviews and reconciliation. The Nursing Coordinator stated during RN Supervisory visits, recertifications and by the nurse caring for the patient from time to time. Both the CEO and Nursing Coordinator were informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Clinical Progress Note dated 4/28/26, showed the patient appears very restless, irritated with crying spells. The physician was notified and patient was sent to an acute hospital for evaluation. The patient was placed on the following medications: -cefdinir (antibiotics) 250/5 ml suspension 60 ml, give 6 ml via GT two times a day for 10 days. -metoclopramide hydrochloride (for nausea and vomiting) 5mg/5ml solution, give 5 ml via GT three times daily as needed. However, the patient’s Medication Profile for Certification Period 3/19/26 to 5/17/26 showed the following medications were administered: -cefpodoxime proxetil (antibiotic) 50mg/5ml powder for suspension, give 20 ml every 12 hours via GT for 10 days. -metoclopramide hydrochloride 5mg/5ml solution, give 5 ml via GT two times a day as needed. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator confirmed the findings. 3. Review of Patient 7’s clinical record was initiated on 6/23/26. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services for 30 certification periods including certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. The Medication Profile for Patient 7 for certification period from 5/26/26 to 7/24/26 showed the patient’s medications included the following: -losartan potassium/hydrochlorothiazide (anti-hypertensive medication) 100 mg – 25 mg tablet, give one tablet one time a day. -Motrin (pain medication) 600 mg oral tablet, administered by mouth, give one tablet two times a day as needed for fever or pain. A joint visit with CHHA 1 was conducted on 6/23/26 at 1300 hours, to Patient 7’s home. The medication bottle for the above medications showed as: -losartan potassium/hydrochlorothiazide (anti-hypertensive medication) 100 mg – 25 mg tablet, give one tablet one time a day. Hold if SBP is less than 105 and HR is less than 55. -Motrin (pain medication) 600 mg oral tablet, take one tablet by mouth every eight hours with food or milk as needed. However, the medications were not updated to show the indication for the SBP, HR and frequency of the above medications. On 6/26/26 at 1106 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator stated the medication review and reconciliation were done during RN Supervisory visit, recertification and as needed. The Nursing Coordinator verified the findings.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7). This failure had the potential of not addressing the care needs for these patients. Findings #1. Review of Patient 5's clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. Review of the OASIS E2 Recertification Assessment dated 3/1/26, showed the Nursing Coordinator had performed a comprehensive assessment. The assessment included the section for Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. In addition, review of the OASIS E2 Recertification Assessment dated 4/30/26, showed the Nursing Coordinator had performed a comprehensive assessment. The assessment included the section for Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. #2. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25. Review of the OASIS E2 Recertification Assessment dated and 5/24/25 and 7/23/25, showed the RN Supervisor had performed a comprehensive assessment. The assessment included the section for Advanced Directive: Living Will, Power of Attorney; Informed of Patients rights in advance of providing hands on care or patient education; DNR status; Spiritual/Cultural Needs; Community/Agencies; Interventions to include teach emergency care plan; discharge plans; skilled interventions to include visit frequency. On 6/26/256at 1120 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. #3. Review of Patient 6's clinical record was initiated on 6/24/26. The clinical record showed the SOC was 1/28/26 The patient was certified for home health services during the certification periods from 3/29/26 to 5/27/26 and 5/28/26 to 7/26/26. Review of the OASIS E2 Recertification Assessment dated 3/28/26 and 5/27/26 showed the RN Supervisor had performed a comprehensive assessment. The assessment included the section for the Emergency Disaster /Disaster code; Advance Directives: Living Will, Power of Attorney, Patient Legal Representative, Patient chosen caregiver, and scope they will perform, inform patient and their right in advance of providing hands on care or patient education; DNR status; Allergies; Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. On 6/26/26 at 1013 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. Review of the Recertification Assessments dated 3/23/26 and 5/22/26, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Recertification Assessments dated 3/18/26 and 5/17/26, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3.Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Recertification Assessment dated 9/20/25, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 4. Review of Patient 7’s clinical record was initiated on 6/23/26. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services for 30 certification periods including certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. Review of the Recertification Assessments dated 3/22/26 and 5/21/26, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1054 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge assessment was completed for two of seven sampled patients (Patients 3 and 4). This failure had the potential for not addressing the care needs for these patients. Findings: #. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25. Review of the Physician Order dated 8/19/25 showed Patient 3 was discharged from the hospice service. Review of the Summary (Non- OASIS) showed check mark on the section for a discharge summary. However, review of the closed clinical record failed to show documented evidence of a discharge OASIS was completed. On 6/26/256at 1120 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if a discharge OASIS was completed for the patient. The Administrator/DPCS replied, it should be. The Administrator/DPCS was also asked as to the timeline for the completion of the discharge OASIS. The Administrator/DPCS replied, on the day of the discharge, it was missing on the electronic record. The Administrator/DPCS was informed and acknowledged the finding. Review of the agency’s P&P titled Patient Discharge Process (undated) showed discharge planning is initiated for every home care patient at the time of the patient’s admission for home care. The discharge procedure including planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. A discharge OASIS assessment will be completed as appropriate. 1. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Physician Order dated 11/5/25, showed the PCG decided to transfer the patient to another home health agency, however, the order read back and verified with MD and patient consulted and provided consent to planned services and care provided in this order was not checked. Further review of the clinical records showed a Non-OASIS Summary was completed on 11/5/25 for Patient 4. However, there was no documented evidence a Discharge OASIS or discharge assessment was completed. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator stated a Discharge OASIS should be completed. The Nursing Coordinator acknowledged and confirmed the findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was notified promptly related to the changes of conditions for one of seven sampled patients (Patient 4). This failure had the potential of not providing quality of care and services to the patient receiving services from the HHA. Findings: Review of the agency’s P&P titled Change in Patient Condition revised 1/17/20, showed all licensed nursing staff are expected to assess the patient’s condition every visit and instruct the caregiver to observe and recognize the changes in patient’s condition. If the licensed nurse observes any change in patient’s condition which is not life threatening, the attending physician should be notified immediately. If the licensed nurse observes that the patient’s change in condition is serious and life threatening, she/he should call 911 immediately. He or she will then, notify the attending physician and nurse supervisor. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification periods from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Clinical Progress Notes dated 10/14 and 10/15/25, showed the patient had a small boil on top of the penis. The boil was red and drained with no pus. However, there was no documented evidence the physician was notified about the patient’s boil on top of the penis. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator was informed and stated the change in condition should be reported to the physician. The Nursing Coordinator acknowledged confirmed the finding.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services were integrated in the POC for one of seven sampled patients (Patient 2). This failure had the potential of not providing quality care and services to the patient. Findings: Review of the agency’s P&P titled Coordination of Patient Services (undated) showed all personnel furnishing services shall maintain a liaison to assure their efforts are coordinated effectively and support the objectives outlined in the Plan of Care. This may be done through formal care conferences, maintaining complete, current care plans; and written and verbal interaction. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Home Health Certification and Plan of Care for certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, showed if during SN visit, the SBP less than 90 mmHg or more than 140 mmHg and DBP less than 60 mmHg and more than 95 mmHg, to notify the physician. Review of the SN visit frequency showed the SN had 56 hours of visits per week from 3/19/26 to 5/17/26 and 5/18/26 to 6/20/26. Review of the Clinical Progress Notes showed the BP was taken on 4/17 and 4/18/26; however, there was no documented evidence the BP was taken on other SN visits and coordinated with the nurse supervisor or physician for the reason why the BP was not taken during every visit. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide written instructions outlining the visit schedule for one of seven sampled patients (Patient 5). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 5's clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. The POC, for the certification period from 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per the PCG's discretions in situations where the patient required more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. A joint home visit with LVN 1 was conducted on 6/23/26 at 0815 hours, to Patient 5's home. Review of the patient’s home folder was conducted with LVN 1. However, there was no documented evidence of the written instructions outlining the SN visit schedules on the home folder. An interview was conducted with the PCG. The PCG was asked if the agency had provided her with the visit schedule. The PCG replied she had her my own calendar. On 06/23/26 at 0941 hours, an interview and concurrent agency document review was conducted with LVN 1. LVN 1 was asked if a visit schedule was available in the home folder. LVN 1 replied none because the visit schedule was permanent, from Monday to Friday, eight hours a day from 0700 hours to 1500 hours. On 6/26/26 at 1249 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide care and services as per the POC for five of seven sampled patients (Patients 1, 2, 3, 4, and 5). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: #1. Review of Patient 5's clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. *The POC showed the patient was on G-tube water flush with the following schedules. -Give 200 ml water via GT before breakfast with meds. -Give 300 ml water via GT after breakfast. -Give 125 ml water via GT before lunch. -Give 125 ml water via GT after lunch. Review of the SN visit notes for example dated 5/8, 5/12, 5/22, 5/27, 6/1, 6/9, and 6/16 /26 showed the SN had given water. However, there was no documented evidence if the water flush was given with medications as ordered in the POC. *Review of the POC showed SN to reposition the patient every two hours and PRN Q shift. Review of the Treatment Record on the following dates showed the SN had repositioned the patient for example: -on 5/1/26 - 0740, 1110 -on 5/7/27 - 0740, 1100 -on 5/8/26 - 0740, 1100 However, the SN failed to repositioned the patient every two hours as ordered in the POC. b. The POC, for the certification period from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. SN to notify MD for SBP less than 90 or more than 140 , DBP less than 60 or more than 95, Pulse less than 60 or more than 120. Review of the SN visit notes on the following for example: -On 3/4/26: BP = 156/101 -On 3/5/26: BP = 152/103 -On 3/6/26: BP = 152/103 -On 3/9/26: BP = 160/104 -On 3/10/26: BP = 160/104 -On 3/11/26: BP = 155/93 -On 3/12/26: BP = 159/106 -On 3/13/26: BP = 154/102 However, review of the clinical records failed to show documented evidence of the SN had notified the physician of the elevated BP as ordered in the POC. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. #2. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25. The POC, for the certification period from for the certification period from 5/25/25 to 7/23/25 cited SN visits 1 to 178 hours per month or 1 to 1068 hours per 180 days (1068 hours/180 days can be used per PCG'S discretions in situations where patient requires more than 178 hours/month) for assessment, observation, evaluation of all body systems and home safety. The POC also includes Intravenous fluids of D5W Lactated Ringers 1000 ml Intravenous two times a week on TPN off days. Review of the SN visit notes showed on Week 7 ( 7/6to 12/25) showed the RN 1 had provided the Intravenous fluids one time on 7/7/25 instead of two times as ordered in the POC. Moreover, there was no documented evidence of the RN 1 had provided the intravenous fluid from Weeks 1, 2, 3,4, 5, 6, 8 and 9 as ordered in the POC. On 6/26/26 at 1140 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if the POC was followed. The Administrator/DPCS replied, it was the PCG provides the D5LR, it was documented on the medication profile. The Administrator/DPCS was asked if there was a documented evidence to show the IV fluids was given two times a week as ordered in the POC. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Care Plans (undated) showed each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs. This plan is developed with the patient and family, as indicated, and is based on services needed to achieve specific measurable goals. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. Review of the Home Health Certification and Plan of Care for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26 showed on Orders for Discipline and Treatment during SN visit for the following: -May dissolve medications or flush GT with up to 50 ml of water for medication administration. -Administer Peptamen Prebio (enteral nutrition formula) 1.0 (250 ml/carton) via GT pump at 55 ml/hr continuously for 22 hours a day. Can decrease GT pump rate to 40 ml/hr if patient is not tolerating. However, review of the Clinical Progress Note in the Time/Intake/Output for the certification period 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed visits wherein SN had not dissolved medications or flush GT with up to 50 ml of water and had nt decreased Peptamen Prebio 1.0 via GT pump rate to 40 ml/hr which is inconsistent with the POC. For example: -On 3/27/26, at 1210 hours SN had administered medication with 120 ml of water, at 1500 hours administered Peptamen Prebio 1.0 at 35 ml/hr and at 1800 hours administered medications with 120 ml of water. -On 4/1/26, at 1210 hours SN had administered medication with 120 ml of water, at 1600 hours administered Peptamen Prebio 1.0 at 30 ml/hr and at 1800 hours administered medications with 120 ml of water. -On 5/1/26, at 1300 hours SN had administered Peptamen Prebio 1.0 at 35 ml/hr and at 1800 hours administered medications with 120 ml of water. -On 6/2/26, at 1210 hours SN had administered medication with 120 ml of water, at 1300 hours administered Peptamen Prebio 1.0 at 30 ml/hr and at 1800 hours administered medication with 120 ml of water. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Home Health Certification and Plan of Care for certification periods 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26 shown in Orders for Discipline and Treatment during SN visit to reposition patient every 2 hours or as needed. However, review of the Treatment Record showed Patient 2 was not repositioned every two hours or as needed which was inconsistent with the POC. For example: -On 3/19/26, SN had a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0934 hours. -On 4/2/26, SN had a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0920 hours. -On 5/1/26, SN had a 10-hour shift from 0700 hours to 1700 hours. Patient 2 was repositioned at 0720 hours. -On 6/1/26, SN had a 12-hour shift from 0800 hours to 2000 hours. Patient 2 was repositioned at 0820 hours. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Home Health Certification and Plan of Care for certification period for 9/21/25 to 11/19/25, shown in the Orders for Discipline and Treatments during SN visits to check for temperature every four hours. However, review of the Treatment Record did not show temperature was checked every four hours, which was inconsistent with the POC. For example: -On 9/23/25, SN had an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. Temperature was checked at 1400 hours then at 2200 hours. -On 10/7/25, SN had an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. Temperature was checked at 1400 hours then at 2200 hours. -On 11/1/25, SN had a seven-hour shift from 1530 hours to 2230 hours. The Treatment Record showed to check temperature every four hours. Temperature was checked at 1540 hours then at 2113 hours. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. Review of the agency’s P&P titled Care Plans (undated) showed each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs. This plan is developed with the patient and family, as indicated, and is based on services needed to achieve specific measurable goals. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. Review of the Home Health Certification and Plan of Care for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed the Orders for Discipline and Treatment included the following: -May dissolve medications or flush GT with up to 50 ml of water for medication administration. -Administer Peptamen Prebio (enteral nutrition formula) 1.0 (250 ml/carton) via GT pump at 55 ml/hr continuously for 22 hours a day. Can decrease GT pump rate to 40 ml/hr if the patient not tolerating. However, review of the Clinical Progress Note in the Time/Intake/Output for the certification period 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed the SN did not followed the POC. For example: -On 3/27/26, at 1210 hours, the SN had administered medication with 120 ml of water; at 1500 hours, administered Peptamen Prebio 1.0 at 35 ml/hr; and at 1800 hours, administered medications with 120 ml of water. -On 4/1/26, at 1210 hours, the SN had administered medication with 120 ml of water; at 1600 hours, administered Peptamen Prebio 1.0 at 30 ml/hr; and at 1800 hours, administered medications with 120 ml of water. -On 5/1/26, at 1300 hours SN had administered Peptamen Prebio 1.0 at 35 ml/hr and at 1800 hours, administered medications with 120 ml of water. -On 6/2/26, at 1210 hours SN had administered medication with 120 ml of water, at 1300 hours administered Peptamen Prebio 1.0 at 30 ml/hr and at 1800 hours administered medication with 120 ml of water. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Home Health Certification and Plan of Care for certification periods 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, showed the Orders for Discipline and Treatment showing during the SN visit, to reposition patient every 2 hours or as needed. However, review of the Treatment Record showed Patient 2 was not repositioned every two hours or as needed as per the POC. For example: -On 3/19/26, the SN was on duty for a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0934 hours. -On 4/2/26, the SN was on duty for a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0920 hours. -On 5/1/26, the SN was on duty for a 10-hour shift from 0700 hours to 1700 hours. Patient 2 was repositioned at 0720 hours. -On 6/1/26, the SN was on duty for a 12-hour shift from 0800 hours to 2000 hours. Patient 2 was repositioned at 0820 hours. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Home Health Certification and Plan of Care for certification period for 9/21/25 to 11/19/25, shown the Orders for Discipline and Treatments showing during the SN visits, to check for temperature every four hours. However, review of the Treatment Record did not show the temperature was checked every four hours as per the POC. For example: -On 9/23/25, the SN was on duty for an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. The patient's temperature was checked at 1400 hours, then at 2200 hours. -On 10/7/25, the SN was on duty for an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. The patient's temperature was checked at 1400 hours then at 2200 hours. -On 11/1/25, the SN was on duty for a seven-hour shift from 1530 hours to 2230 hours. The Treatment Record showed to check temperature every four hours. The patient's temperature was checked at 1540 hours then at 2113 hours. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 4. Review of Patient 5's clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. *The POC showed the patient was on the GT water flush schedule as follows: -Give 200 ml water via GT before breakfast with medications. -Give 300 ml water via GT after breakfast. -Give 125 ml water via GT before lunch. -Give 125 ml water via GT after lunch. Review of the SN visit notes dated 5/8, 5/12, 5/22, 5/27, 6/1, 6/9, and 6/16 /26, showed the SN had given water. However, there was no documented evidence if the water flush was given with the medications as ordered in the POC. *Review of the POC showed the SN to reposition the patient every two hours and PRN Q shift. Review of the Treatment Record showed the SN did not followed the POC regarding reposition of the patient. For example: -on 5/1/26, the patient was reposition at 0740 and 1110 hours -on 5/7/27, the patient was reposition t 0740 and 1100 hours -on 5/8/26, the patient was reposition at 0740 and 1100 hours b. The POC, for the certification period from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per the PCG's discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety; and SN to notify MD for SBP less than 90 mmHg or more than 140 mmHg , DBP less than 60 mmHg or more than 95 mmHg, Pulse less than 60 bmp or more than 120 bmp. Review of the SN visit notes showed the following: -On 3/4/26, BP = 156/101 mmHg -On 3/5/26, BP = 152/103 mmHg -On 3/6/26, BP = 152/103 mmHg -On 3/9/26, BP = 160/104 mmHg -On 3/10/26, BP = 160/104 mmHg -On 3/11/26, BP = 155/93 mmHg -On 3/12/26, BP = 159/106 mmHg -On 3/13/26, BP = 154/102 mmHg However, review of the clinical record failed to show documented evidence the SN had notified the physician of the elevated BP as ordered in the POC. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 5. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25.The POC, for the certification period from for the certification period from 5/25/25 to 7/23/25 cited SN visits 1 to 178 hours per month or 1 to 1068 hours per 180 days (1068 hours/180 days can be used per PCG'S discretions in situations where patient requires more than 178 hours/month) for assessment, observation, evaluation of all body systems and home safety. The POC also includes Intravenous fluids of D5W Lactated Ringers 1000 ml Intravenous two times a week on TPN off days. Review of the SN visit notes showed on Week 7 ( 7/6to 12/25) showed the RN 1 had provided the Intravenous fluids one time on 7/7/25 instead of two times as ordered in the POC. Moreover, there was no documented evidence of the RN 1 had provided the intravenous fluid from Weeks 1, 2, 3,4, 5, 6, 8 and 9 as ordered in the POC. On 6/26/26 at 1140 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if the POC was followed. The Administrator/DPCS replied, it was the PCG provides the D5LR, it was documented on the medication profile. The Administrator/DPCS was asked if there was a documented evidence to show the IV fluids was given two times a week as ordered in the POC. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical notes for three of seven sampled patients (Patients 1, 2, and 5) were accurate. This failure had the potential for substandard healthcare outcomes to these patients. Findings: #. Review of Patient 5's clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite1.5 cal via G.Tube. Review of the SN visit notes for example dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. b. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite 1 .5 cal via G Tube. Review of the SN visit notes for example dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. c. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the "Thripple" antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to what was the medication for. The Administrator/DPCS replied, it was inaccurate documentation. The Administrator/DPCS was informed and acknowledged the findings. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the "Thripple" antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Clinical Documentation (undated) showed the agency will document each direct contact with the patient. The purpose of the clinical documentation was to ensure that there is an accurate record of the services provided, patient response and ongoing need for care. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. a.Review of the Recertification Assessment dated 3/23 and 5/22/26 both showed in the Bladder and Bowel Section, the patient continues to require vent GT as needed due to gas, bloated stomach. Daily insert of dover red rubber urethral catheter 16 French (5.3 mm) via anus to release abdominal air distention and as needed. However, review of the Home Health Certification Plan of Care for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26 showed in the Orders for Discipline and Treatment for both certification periods to insert dover red rubber urethral catheter 20 French via anus to release air as needed which was inconsistent with the Recertification Assessments. b.Review of the Clinical Progress Note documented on the SN visits showed in the Gastrointestinal Section the number of times patient had a BM which was inconsistent with Intake/Output section for the stool. For example: -On 5/23/26, LVN 2 documented patient had one-time medium BM which was inconsistent with the documentation in the Output section of one large BM. -On 6/12/26, LVN documented patient had nine times BM, however, there was no documented BM in the Output section. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. a. Review of the Clinical Progress Note documented on the SN visits shown in the Gastrointestinal Section, the number of times patient had a BM which was inconsistent with Intake/Output section for the stool. For example: -On 4/14/26, LVN 3 documented patient had BM four times which was inaccurate with the documentation in the Output section of BM six times. -On 4/24/26, LVN 3 documented patient had BM four times which was inconsistent with the documentation in the Output section of BM seven times. b. Review of the Clinical Progress Note for 4/20, 4/21, 4/23, 4/24, 4/25, and 4/27/26, showed LVN 3 assessed Patient 2 has no pain, however, grinding of teeth was checked on the behavior for pain, which was inconsistent with the pain assessment. c.Review of the Clinical Progress Note dated 6/16/26, showed Respiratory function was assessed, however, oxygen saturation was left blank. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. Review of the agency’s P&P titled Clinical Documentation (undated) showed the agency will document each direct contact with the patient. The purpose of the clinical documentation was to ensure that there is an accurate record of the services provided, patient response, and ongoing need for care. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. a. Review of the Recertification Assessment dated 3/23 and 5/22/26, showed the patient continued to require vent GT as needed due to gas, bloated stomach. Daily insert of dover red rubber urethral catheter 16 French (5.3 mm) via anus to release abdominal air distention and as needed. However, review of the Home Health Certification Plan of Care, for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed to insert dover red rubber urethral catheter 20 French via anus to release air as needed which was inconsistent with the Recertification Assessments. b. Review of the Clinical Progress Notes showed inconsistent information on the Gastrointestinal section and Output section. For example: -On 5/23/26, the Gastrointestinal section showed the patient had one-time medium BM which was inconsistent with the Output section of one large BM. -On 6/12/26, the Gastrointestinal section showed the patient had nine times BM; however, there was no documented BM in the Output section. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. a. Review of the Clinical Progress Notes showed inconsistent information on the Gastrointestinal section and Output section. For example: -On 4/14/26, the Gastrointestinal section showed the patient had BM four times which was inconsistent with the Output section of six times BM. -On 4/24/26, the Gastrointestinal section showed the patient had BM four times which was inconsistent with the Output section of seven times BM. b. Review of the Clinical Progress Note for 4/20, 4/21, 4/23, 4/24, 4/25, and 4/27/26, showed Patient 2 had no pain; however, grinding of teeth was checked on the behavior for pain, which was inconsistent with the pain assessment. c.Review of the Clinical Progress Note dated 6/16/26, showed Respiratory function was assessed, however, oxygen saturation was left blank. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3. Review of Patient 5's clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite1.5 cal via G-Tube. Review of the SN visit notes for example dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. b. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite 1 .5 cal via G Tube. Review of the SN visit notes for example dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. c. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the "Thripple" antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to what was the medication for. The Administrator/DPCS replied, it was inaccurate documentation. The Administrator/DPCS was informed and acknowledged the findings. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the "Thripple" antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of seven sampled patients (Patient 2). Findings: Review of the agency’s P&P titled Clinical Supervision revised 3/30/20, showed skilled nursing and other therapeutic services are provided under the supervision of a Registered Nurse to assure employee performance is appropriately supervised, that care is directed toward the achievement of goals, and that services are provided based on patient need and in accordance with the physician’s Plan of Care. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the LVN Supervisory Note dated 4/17 and 5/17/26, showed the Nurse Supervisor evaluated the services of LVN 3. The evaluation showed LVN 3 exceeded requirements for adhering to the plan of treatment. LVN 3 provided excellent care and followed plan of care. Review of the Home Health Certification and Plan of Care, for certification periods 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, showed to reposition patient every 2 hours or as needed during SN visit. Review of the Treatment Record failed to show LVN 3 had repositioned the patient every two hours or as needed. For example: -On 3/19/26, LVN 3 had a 12-hour shift from 0900 hours to 2100 hours. LVN 3 repositioned the patient at 0934 hours. -On 4/2/26, LVN 3 had a 12-hour shift from 0900 hours to 2100 hours. LVN 3 repositioned at 0920 hours. -On 5/1/26, LVN 3 had a 10-hour shift from 0700 hours to 1700 hours. LVN 3 repositioned the patient at 0720 hours. -On 6/1/26, LVN 3 had a 12-hour shift from 0800 hours to 2000 hours. LVN 3 repositioned the patient at 0820 hours. However, the RN failed to identify LVN 3 did not provide care as per the POC and ensure adequate supervision provided for the LVN. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator was informed and acknowledged the findings.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the CHHA 12-hour training was completed for one of two CHHA’s reviewed (CHHA 1). This failure had the potential of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the agency’s P&P titled Competency Evaluation of Home Care Staff (undated) showed the Home Health Aide must demonstrate evidence of successful completion of a training program totaling at least 75 hours. At least 16 of those hours must have been devoted to supervised practical training. The individual must complete at least 16 hours of classroom training before beginning the supervised practical training or successful completion of a competency evaluation program. The Home Health Aide will successfully complete the competency evaluation program if he/she demonstrates competency in a minimum of 11 of the 12 areas required in federal guidelines. Review of the employee file for CHHA 1 was initiated on 6/25/26. CHHA 1 was hired on 4/24/23. However, CHHA 1’s employee file showed no documented evidence CHHA 1 had completed the CHHA 12-hour training. On 6/26/26 at 1152 hours, an interview and concurrent agency document review was conducted with the Nursing Coordinator. The Nursing Coordinator was informed confirmed there was no in-service training for CHHA 1.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency's Administrator failed to be responsible for the agency's day-to-day operations related to not implementing the P&Ps as evidenced by: -The annual TB screening was not completed for LVNs 4, 6, and CHHA 1. -The pre-employment physical was not completed for the Nurse Supervisor, LVNs 5, 6, and CHHA 1. -The orientation was not completed for RN 2. -The certification was expired for CHHA 2. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. 1. Review of the agency’s P&P titled Employee TB Screening and Prevention Policy effective 1/2/26, showed all employees shall be screened for TB infection and disease risk at the time of hire and monitored annually for TB risk factors and symptoms. Procedure for pre-employment screening includes all new employees shall complete a baseline TB infection test and TB symptom questionnaire. Review of the personnel files conducted on 6/25/26, showed the following: -LVN 4’s personnel file showed the hired date was 2/20/26. The TB symptom questionnaire was completed on 8/18/25. However, there was no documented evidence a TB infection test was completed for the pre-employment. -LVN 6’s personnel file showed the hired date was 1/22/26. However, there was no documented evidence a TB infection test was completed for the pre-employment. -CHHA 1’s personnel file showed the hired date was 4/24/23. However, there was no documented evidence an annual TB symptom questionnaire was completed for the years of 2024 and 2025. 2. Review of the agency’s P&P titled Health Screening revised 1/19/18, showed each employee having direct contact with patients must have documentation of baseline health screening prior to providing care to patients within 90 days of hire. Health screening will occur after a conditional offer of employment is made. Review of the personnel files conducted on 6/25/26, showed the following: -LVN 5’s personnel file showed the hired date was 1/22/26. However, there was no documented evidence the pre-employment physical examination was completed. -LVN 6’s personnel file showed the hired date was 1/22/26. However, there was no documented evidence the pre-employment physical examination was completed. -CHHA 1’s personnel file showed the hired date was 4/24/23. However, there was no documented evidence the pre-employment physical examination was completed. 3. Review of the agency’s P&P titled Employee Orientation (undated) showed each employee of the agency who provides direct care, supervision of direct care, or management of services, will participate in an orientation program specific to his/her educational background and experience, type of care provided, physical and mental condition of patients, and the roles and responsibilities as an employee of the agency. Review of the employee file for RN 2 was conducted on 6/25/26. RN 2’s personnel file showed the hire date was 12/2/25. However, the employee orientation was blank. 4. Review of the agency’s P&P titled Employment (undated) showed for License Certification, the agency shall obtain copies of updated licensure on an ongoing basis. Review of the employee file for CHHA 2 was conducted on 6/25/26. CHHA 2’s personnel file showed the hire date was 11/17/22. However, CHHA 2’s certification had expired on 3/9/25. On 6/26/26 at 0858 hours, an interview and concurrent record review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION surveys. Representing the California Department of Public Health: Surveyors 39539, HFEN and 31929, HFEN. The survey team entered the HHA on 5/16/23 at 0900 hours. The survey team reviewed five active and two closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: CEO: Chief Executive Officer CHHA: Certified Home Health Aide DPCS: Director of Patient Care Services HHA: Home Health Agency LVN: Licensed Vocational Nurse P&P: Policy and Procedure RN: Registered Nurse

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness plan included strategies addressing the emergency events identified by the risk assessment, creating the increased risk of not addressing the care needs for the patients during the emergency events. Findings: Review of the agency's emergency preparedness program documents was conducted on 5/24/23, and showed the documents included the Disaster Risk Assessment and Emergency Management Plan which showed the HHA was taking the all-hazard approach to for the hazard preparedness for a variety of hazardous events listed in the HHA's Hazard Vulnerability Analysis. Documentation showed values over the score of eight has a high probability of and require planning and preparing for. Documentation showed the events included earthquake, fire, and environmental/altered air quality pollution. * However, there was no documented evidence of the strategies to address the emergency event related to the environmental/altered air quality pollution. On 5/25/23 at 1045 hours, an interview and concurrent document review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P included procedures to inform the state and local officials of any on-duty staff or patients that they are unable to contact. This created the potential risk of not meeting the health, safety, and security needs of their staff and patients' population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness program documents was conducted on 5/25/23. However, the agency's emergency preparedness P&P did not include the procedures to inform the state and local officials of any on-duty staff or patients that they are unable to contact. On 5/25/23 at 1045 hours, an interview and concurrent document review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop a communication plan that included the name and contact information of the staff, entities providing the services under arrangement, and the patients’ physicians, creating the risk of not able to contact or request for assistance during emergency events. Findings: Review of the agency's emergency preparedness program documents was conducted on 5/24/23. There was no documented evidence the communication plan included the name and contact information of the staff, entities providing the services under arrangement, and the patients’ physicians. On 5/25/23 at 1045 hours, an interview and concurrent document review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the finding.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This failure created the risk of not providing the necessary care and services to the patients during emergency events. Findings: Review of the agency's emergency preparedness program documents was conducted on 5/24/23. However, the emergency preparedness communication plan did not include a means of providing information about the agency's ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. On 5/25/23 at 1045 hours, an interview and concurrent document review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the finding.

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 agency failed to ensure the initial training on the emergency preparedness P&P was provided to all new staff. This failure created the risk of the agency's staff not knowing what to do in case of emergency. Findings: Review of the agency’s emergency preparedness program documents was conducted on 5/24/23. Review of the personnel files for CHHAs 1, 2, 3, and LVN 1 was conducted on 5/23/23, and showed the following: CHHA 1 was hired 8/29/21. CHHA 2 was hired on 2/15/23. CHHA 3 was hired on 3/29/21. LVN 1 was hired on 3/14/23. * However, there was no documented evidence the initial training for the emergency preparedness P&P was provided to the above employees. On 5/25/23 at 1045 hours, an interview and concurrent document review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the finding.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS surveys. Representing the California Department of Public Health: Surveyors 39539, HFEN and 31929, HFEN. The survey team entered the HHA on 5/16/23 at 0900 hours. The survey team reviewed five active and two closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL: activities of daily living BID: twice a day BP: blood pressure BM: bowel movement CDC: Centers for Disease Control and Prevention CEO: Chief Executive Officer CHHA: Certified Home Health Aide COVID 19: an infectious disease caused by the SARS-CoV-2 virus DPCS: Director of Patient Care Services gm: gram(s) G-tube: a tube inserted through the abdomen into the stomach used for long-term enteral nutrition GI: Gastrointestinal HHA: Home Health Agency HS: bedtime IM: intramuscular IV: intravenous influenza: acute respiratory infection caused by influenza viruses JT: Jejunostomy tube (a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) LVN: Licensed Vocational Nurse Mantoux tuberculin skin test: one method of determining whether a person is infected with Mycobacterium tuberculosis mcg: microgram(s) meq: milliequivalent(s) mg: milligram(s) mmHg: millimeters of mercury ml: milliliter(s) OT: Occupational Therapy/Therapist PCG: Patient Care Giver OASIS: Outcome and Assessment Information Set P&P: policy and procedure pneumonia: infection that affects one or both lungs. PO: by mouth POC: Plan of Care PRN: As needed PT: Physical Therapy/Therapist Q: Every QAPI: Quality Assurance and Performance Improvement QD: Every day PROM: passive range of motion RCOC: Regional Center of Orange County ROM: range of motion RN: Registered Nurse TPN: total parenteral nutrition (a method of feeding that bypasses the gastrointestinal tract) sepsis: serious condition in which the body responds improperly to an infection SLP: Speech Language Pathologists SN: Skilled Nurse SOC: Start of Care TB: tuberculosis (an infectious disease that most often affects the lungs and is caused by a type of bacteria) tetanus: serious disease of the nervous system caused by a toxin-producing bacterium TID: three times a day URI: Upper Respiratory Infection UTI: Urinary Tract Infection

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the complaints for two of seven sampled patient (Patients 3 and 6) and two nonsampled patients (Patients A and B) were thoroughly investigated, creating the risk not providing quality of care and services to these patients. Findings: Review of the agency’s P&P titled Section 514 Grievance Procedures (undated) showed the coordinator, or designee shall conduct such investigation of a grievance as may be appropriate to determine whether it is valid. a. The Patient Grievance/Complaint form dated 9/28/20, showed according to Patient 6's family member, “the HHA currently providing care tends to verbalize things that are unwarranted, not appreciative, acts negative towards family members, tends to be bossy, pushing the pt (patient) to shower early when he is not ready, eats food with garlic smell that pcg (patient caregiver) does not like, told pcg that he shouldn’t feed pt certain things like pancakes.” The documentation showed the resolution included one on one conference with the SN to discuss feedback, encouraged the SN to show compassion in communication, consideration of patient request while following agency's protocol and an in-service training was provided regarding patient/family communication and relationships. b. The Patient Grievance/Complaint form dated 9/22/21, showed according to Patient A's family member, the SN currently providing care “lacks cultural awareness” and constantly "objects to pcg requests.” The documentation showed the resolution included one on one conference with the SN to discuss feedback, encouraged the SN to show compassion in communication, consideration of patient request while following agency's protocol, and an in-service training was provided regarding patient/family communication and relationships. c. The Patient Grievance/Complaint form dated 11/3/21, showed according to Patient B's family member of the SN currently providing care has a “dominant personality” that he was not comfortable working with. The documentation showed the PCG stated the SN “does not take instruction well” and when he requested for a task to be completed in a certain way, the SN stated “her own ideas” and disregarded his request. The documentation showed the PCG stated the SN did not respect the PCG and gave them attitude. The documentation showed the resolution included one on one conference with the SN to discuss feedback, encouraged the SN to show compassion in communication, consideration of patient/family request while following agency's protocol, and an in-service training was provided regarding patient/family communication and relationships. d. The Patient Grievance/Complaint form dated 2/7/22, showed Patient 3's family member was upset when the nurse called off and there was no replacement nurse ”on call” who can come to provide care at the home immediately. The documentation showed the resolution included the agency reviewed the policy and physician approved home health orders with the PCG that in the event the nurse called off and there is no immediate replacement, the patient’s family was responsible for patient care until the nurse can return. The documentation showed the PCG verbalized understanding. * However, there was no documented evidence of the agency conducted a thorough investigation by interviewing the patient, family members, and regarding the above grievances. On 5/23/23 at 1355 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs for four of seven sampled patients (Patients 2, 3, 5, and 7), creating the risk of not identifying and addressing the care needs timely for these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 10/11/22. The patient was certified for home health services during the certification period from 4/19/23 to 6/7/23. * The OASIS SOC Comprehensive Assessment dated 10/11/22, showed no documented evidence the assessments for the patient’s pulse rate, last BM, external genitalia status, and immunization/screening status related to influenza, pneumonia, tetanus, TB, and known TB exposure were completed. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the finding. 2. Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23 and 4/12/23 to 6/10/23. * The OASIS SOC Comprehensive Assessment dated 8/20/21, showed no documented evidence of the assessments for the patient’s BP, pulse rate, respiratory rate, temperature, immunization/screening status, hearing condition, nasal condition, pharyngeal condition, musculoskeletal status, structural barriers, safety hazards, sanitation hazards, pain status, integumentary status, last BM, bowel sounds, external genitalia, breath sounds, psychological/social status, hand grips, and cardiovascular status were completed. On 5/25/23 at 0958 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 3. Review of Patient 7's closed clinical record was initiated on 5/22/23. The clinical record showed the SOC was 7/19/22. The patient was certified for home health services during the certification periods from 7/19/22 to 9/16/22 and 9/17/22 to 11/15/22. * The OASIS SOC Comprehensive Assessment dated 7/19/22, showed no documented evidence of the assessments for the patient’s sleep/rest status and immunization/screening status related to influenza, pneumonia, tetanus, TB, and known TB exposure were completed. On 5/25/23 at 1022 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 4. Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23 and 5/13/23 to 7/11/23. The OASIS SOC dated 3/14/23, showed no documented evidence the assessments for the patient’s immunization/screening status related to pneumonia, tetanus, TB, and known TB exposure were completed. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

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 agency failed to ensure the medication profiles were updated to reflect the patients' current medications and included specific indications and parameters for their use for four of seven sampled patients (Patients 1, 3, 4, and 5). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. Findings: 1. Review of Patient 1's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 12/15/14. The patient was certified for home health services during the certification periods from 3/3/23 to 5/1/23, and 5/2/23 to 6/30/23. The medication profile showed the patient’s medications included cetirizine hydrochloride (antihistamine) 10 mg one tablet QD PRN via JT for allergy relief and diphenhydramine hydrochloride (antihistamine) 2 mg dissolve one tablet in 5 ml of water PRN for allergy relief. * However, the physician's order did not include when to administer the above medications which were for the same indication of allergy relief; and the frequency to administer the PRN diphenhydramine hydrochloride. On 5/25/23 at 0937 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the finding. 2. Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23. The POCs, for the certification periods from 2/11/23 to 4/11/23 and 4/12/23 to 6/10/23, cited CHHA shift care 0-240 hours/month, 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by Medi-Cal Waiver Program. The medication profile, for the certification period from 4/12/23 to 6/10/23, included Ativan (antianxiety) 2 mg/ml solution for injection 1 mg IM for seizure activity, baclofen (muscle relaxant) 10 mg three tablets PO at bedtime, divalproex sodium (anticonvulsant) 250 mg delayed release two tablets PO BID, levetiracetam (anticonvulsant) 1000 mg two tablets PO Q 12 hours, Senna (laxative) 8.6 mg two tablets PO at bedtime, topiramate (anticonvulsant) 200 mg one tablet PO Q 12 hours, and Tylenol (analgesic) 325 mg two tablets PO Q six hours PRN for temperature of 100.5 degrees Fahrenheit and above. A joint home visit with CHHA 1 was conducted on 5/17/23 at 1000 hours hours, to Patient 3’s home. Review of the medications with the family member, showed the patient was no longer on baclofen, topiramate, Tylenol, and Ativan. The family member stated the current dose of levetiracetam was 500 mg two tablets in the morning and evening instead of 1000 mg two tablets PO Q 12 hours, Senna was administered PRN instead of routine, and the patient was on Motrin (nonsteroidal anti-inflammatory drug) 600 mg PO BID PRN. On 5/25/23 at 0958 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 3. Review of Patient 4’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/7/18. The patient was certified for home health services during the certification periods from 2/13/23 to 4/13/23 and 4/14/23 to 6/12/23. The medication profile, for the certification period from 4/14/23 to 6/12/23, showed diphenhydramine (antihistamine) 12.5 mg/5 ml solution give 5 ml QD at night via G-tube, D-Mannose (supplement) one capsule one to two times daily PRN when there are sign and symptoms of UTI, melatonin (supplement) 3 mg one tablet Q HS via G-tube, montelukast (used for allergic rhinitis) chewable tablet 4 mg Q night at bedtime via G-tube. A joint home visit with LVN 2 was conducted on 5/17/23 at 1250 hours, to Patient 4’s home. Review of the medication with LVN 2 showed the patient was currently on the following medications: - diphenhydramine 12.5 mg/5 ml solution via G-tube PRN, instead of QD at night as per the medication profile. - D-Mannose one capsule one to two times daily, instead of PRN as per the medication profile. - melatonin 5 mg one tablet Q HS via G-tube, instead of 3 mg as per the medication profile. - montelukast 10 mg chewable tablet Q night at bedtime via G-tube, instead of 4 mg as per the medication profile. On 5/17/23 at 1250 hours, an interview and concurrent clinical record review was conducted with LVN 2. She was informed and acknowledged the findings. On 5/23/23 at 1500 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings. 4. Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23. The medication profile, for the certification period from 5/13/23 to 7/11/23, showed the patient’s medication included lamotrigine (anticonvulsant) 150 mg QD via G-tube; potassium chloride (supplement) 20 meq/15 ml oral solution give 5 ml Q morning, afternoon, and night via G-tube; and polyethylene glycol 3350 (laxative) 17 gm powder for oral solution, mix 17 gm with 120 to 240 ml liquid QD PRN via G-tube for constipation. A joint home visit with LVN 1 was conducted on 5/18/23 at 1055 hours, to Patient 5’s home. Review of the medication with LVN 1, showed the patient was on lamotrigine 150 mg PO BID via G-tube, instead of QD as per the medication profile; potassium chloride 20 meq/15 ml PO QD, instead of 5 ml Q morning, afternoon and night as per the medication profile, and the patient was no longer taking polyethylene glycol. On 5/18/23 at 1130 hours, an interview and concurrent clinical record review was conducted with LVN 1. She was informed and acknowledged the findings. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the finding.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last 5 days of every 60 days for seven of seven sampled patients (Patient 1, 2, 3, 4, 5, 6, and 7), creating the increased risk of not addressing the care needs for these patients. Findings: 1. Review of Patient 1's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 12/15/14. The patient was certified for home health services during the certification periods from 3/3/23 to 5/1/23, and 5/2/23 to 6/30/23. * The OASIS Recertification dated 3/2/23, showed no documented evidence of the assessments for the patient’s BP, pulse rate, respiration rate, weight, immunization/screening status, bowel sounds completed. * The OASIS Recertification dated 5/1/23, showed no documented evidence the assessments for the patient’s BP, pulse rate, respiration rate, weight, immunization/screening status, hand grips, and pupils were completed. On 5/25/23 at 0937 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 10/11/22. The patient was certified for home health services during the certification period from 4/19/23 to 6/7/23. * The OASIS Recertification dated 4/4/23, showed no documented evidence an assessment of the patient’s immunization/screening status was completed. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 3. Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23. * The OASIS Recertification dated 2/6/23, showed no documented evidence the assessment of the patient’s immunization/screening status and bowel sounds were completed. * The OASIS Recertification dated 4/7/23, showed no documented evidence the assessments of the patient’s BP, pulse rate, respiratory rate, and temperature, bowel sounds, and immunization/screening status related to influenza, pneumonia, tetanus, TB, and known TB exposure were completed. On 5/25/23 at 0958 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 4. Review of Patient 7's closed clinical record was initiated on 5/22/23. The clinical record showed the SOC was 7/19/22. The patient was certified for home health services during the certification periods from 7/19/22 to 9/16/22, and 9/17/22 to 11/15/22. * The OASIS Recertification Comprehensive dated 9/13/22, showed no documented evidence the assessments of the patient’s BP and immunization/screening status were completed. On 5/25/23 at 1055 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 5. Review of Patient 4’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/7/18. The patient was certified for home health services during the certification periods from 2/13/23 to 4/13/23, and 4/14/23 to 6/12/23. The Pediatric Assessment Recertication dated 2/12/23, showed no documented evidence the assessments of the patient’s BP, pulse rate, respiration rate, and immunization status were completed. On 5/23/23 at 1500 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings. 6. Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23. The OASIS Recertification dated 5/12/23, showed no documented evidence the assessments of the patient’s BP, pulse rate, respiratory rate, pupil status, and immunization/screening status related to pneumonia, tetanus, TB, and known Tb exposure were completed. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings. 7. Review of Patient 6’s closed clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/16/20. The patient was certified for home health services during the certification periods from 5/9/22 to 7/7/22 and 7/8/22 to 9/5/22. The OASIS Recert Comprehensive dated 5/4/22, showed no documented evidence the assessments of the patient’s weight, height, and immunization/screening status were completed. The OASIS Recert Comprehensive dated 7/3/22, showed no documented evidence the assessments of the patient’s weight, height, respiratory rate, and immunization/screening status were completed. On 5/23/23 at 1250 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

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, the agency failed to ensure the POC included specific information related to the frequency of visits to be made, mental status, activities permitted, and enteral interventions for five of seven sampled patients (Patient 1, 2, 3, 4, and 7). This failure created the risk of not providing necessary services for these patients. Findings: 1. Review of Patient 1's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 12/15/14. The patient was certified for home health services during the certification periods from 3/3/23 to 5/1/23, and 5/2/23 to 6/30/23. The POCs, for the certification periods from 3/3/23 to 5/1/23 and 5/2/23 to 6/30/23, cited RN to provide 0-72 hours per week or 0-1851 hours/180 days (1851 hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 72 hours/week), and RN supervisory visit one time a month according to Treatment Authorization Request authorized by the Medi-Cal Waiver Program. The POC included LVN Respite Care 0-24 hours/month or 0-288 hours/year through the RCOC (288 respite hours/year can be used per PCGs discretion in situations where patient requires more than 24 respite hours/month). * However, the frequency of the visit included 0 as a lower range of the visit hours per week, month, 180 days, and year. On 5/25/23 at 0937 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 10/11/22. The patient was certified for home health services during the certification period from 4/19/23 to 6/7/23. The POC, for the certification period from 4/9/23 to 6/7/23, cited CHHA shift care 0-240 hours/month or 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by the “HCBA Waiver Program.” * However, the frequency of the visit included 0 in the lower range of the visit hours per month and 180 days. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 3. Review of Patient 7's closed clinical record was initiated on 5/22/23. The clinical record showed the SOC was 7/19/22. The patient was certified for home health services during the certification periods from 7/19/22 to 9/16/22, and 9/17/22 to 11/15/22. a. The POC, for the certification period from 7/19/22 to 9/16/22, showed SN may flush G-tube with water before or after feeding PRN to keep G-tube patent. The Physician Order dated 7/19/22, showed to administer Keto functional formularies (tube feeding formula and meal replacement) one bag/240 ml three times daily at about six hours apart via G-tube. Documentation showed, “Water or juice. Give ad lib via (as desired) G-tube for hydration.” * However, the physician's order did not include the specific amount of how much water or juice to be administered to the patient. b. The physician’s order dated 9/13/22, showed LVN shift care 0-240 hours /month or 1440 hours/180 days (1440 hours/180 days can be used per the PCG’s discretion in situation where the patient would require more than 240 hors/month), and RN supervisory visit one time a month according to the Treatment Authorization Record authorized by the “HCBA Waiver Program.” * However, the frequency of the visit included 0 in the lower range of the visit hours per month and 180 days. On 5/25/23 at 1022 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the finding. 4. Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23. The POC, for the certification period from 2/11/23 to 4/11/23 and 4/12/23 to 6/10/23, cited CHHA shift care 0-240 hours/month, 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by Medi-Cal Waiver Program. * However, the frequency of the visit included 0 in the lower range of the visit hours per month and 180 days. On 5/25/23 at 0958 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the finding. 5. Review of Patient 4’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/7/18. The patient was certified for home health services during the certification periods from 2/13/23 to 4/13/23, and 4/14/23 to 6/12/23. a. The POC, for the certification periods from 2/13/23 to 4/13/23 and 4/14/23 to 6/12/23, showed LVN Skilled Nursing 0-112 hours/week or 0-960 hours/ 60days (960 hours/60 days can be used per the PCG’s discretion in situations where the patient would require more than 112 hours/week); and RN supervisory visit one time a month according to service authorization as approved by the pediatric health network. The POC included LVN respite care 0-24 hours/month or 0-288 hours/year through the RCOC; respite hours to be used concurrently and/or interchangeably with skilled nursing hours depending on the patient/PCG necessity; 288 respite hours/year can be used per tje PCG’s discretion in situations where the patient would require more than 24 respite hours/month or more than 112 skilled nursing hours/week. * However, the frequency of the visit included 0 in the lower range of the visit hours per week, month, 60 days, and year. b. Review of the POC, for the certification periods from 4/14/23 to 6/12/23, showed the POC did not include the patient’s mental status and activities permitted. On 5/23/23 at 1500 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the verbal orders were signed by the physician in a timely manner for two of seven sampled patients (Patients 4 and 5). This failure created the risk of not appropriately authenticating the contents of the patients' clinical record. Findings: Review of the HHA state regulation, Title 22 Chapter 6, 74697 (a) a written plan of treatment shall be established for each patient whose care requires medical orders. A plan of treatment or plan or care for patients requiring medical orders shall be (a) approved and signed within 30 working days by the attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice. 1. Review of Patient 4’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/7/18. The patient was certified for home health services during the certification periods from 2/13/23 to 4/13/23, and 4/14/23 to 6/12/23. The physician’s order dated 3/1/23, showed Onfi (sedative) 2.5 mg/ml 1.5 ml daily at HS via G-tube. The physician’s order dated 3/8/23, showed Onfi 2.5 mg/ml to give one ml at daily HS via G-tube. The physician’s order dated 3/14/23, showed Onfi 2.5 mg/ml to give 0.5 ml at daily at HS via G-tube. The physician’s order dated 3/22/23, showed to discontinue Onfi 2.5 mg/ml. The physician’s order dated 3/28/23, showed clonazepam (antianxiety) ODT 0.25 mg one tablet PRN via G-tube for cluster seizures, not exceed three doses daily. The physician’s order dated 3/29/23, showed Valtoco (anticonvulsant) 5 mg one spray by nasal route one time PRN for cluster seizures, one spray in one nostril. * However, there was no documented evidence of a physician’s signature for the above orders. On 5/23/23 at 1500 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23. The physician’s order dated 4/12/23, showed Vitamin B 12 (supplement) 1000 mcg one tablet daily via G-tube. * However, there was no physician’s signature for the above order. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POC was revised for one of seven sampled patients (Patient 1), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 1's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 12/15/14. The patient was certified for home health services during the certification periods from 3/3/23 to 5/1/23, and 5/2/23 to 6/30/23. The physician's order dated 1/9/23, showed to administer Lactated Ringers (type of IV fluid) 50 ml/hour for 12 hours. The POCs, for the certification periods from 3/3/23 to 5/1/23 and 5/2/23 to 6/30/23, showed to administer Lactated Ringers Solution for injection intravenous via Curlin pump (delivers fluid in smaller, more accurate increments), infuse one bag (2000 ml) over 12 hours twice a week on non-TPN days every Tuesday and Saturday. However, review of the SN note dated 3/12/23 (Sunday), and 3/13/23 (Monday) showed Lactated Ringers Solution was administered, which was no consistent with the POC. On 5/25/23 at 0937 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. The RN Supervisor stated the POC was not updated to reflect the correct order. The RN Supervisor stated the physician's order dated 1/9/23, should have carried over on the POC, for the certification periods from 3/3/23 to 5/1/23 and 5/2/23 to 6/30/23. They were informed and acknowledged the findings.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide the name and contact information of the clinical manager for one of five sampled patient (Patient 5). This failure created the risk of not providing the necessary information to this patient. Findings: Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23. The POC, for the certification period from 5/13/23 to 7/11/23, showed LVN Shift Care 0-210 hours/month or 1260 hours/180 days, and RN supervisory visit one time a month according to the Treatment authorization request as authorized by the “HCBA Waiver Program.” On 5/18/23 at 1055 hours, a joint home visit was conducted with LVN 1 to Patient 5’s home. Review of the patient's admission packet provided by the HHA failed to include the name and contact information of the HHA's clinical manager. On 5/18/23 at 1130 hours, an interview and concurrent clinical record review was conducted with LVN 1. She was informed and acknowledged the findings. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement and maintain the infection control program including surveillance, identification, prevention, and control, creating the risk of the spread of infections. Findings: Review of the agency's P&P titled Infectious Disease Reporting dated 1/19/2021, showed the following: - The agency will identify and report incidences of infectious diseases identified in patient and employees, as appropriate. - The Director of Nursing designee will be responsible for assuring compliance with the infectious disease reporting rules. - Infections identified in the patients after admission that will be reported includes: a. Urinary tract infections requiring physician intervention. b. Upper and/or lower respiratory tract infections requiring physician intervention. c. Wound infections d. Peripheral or central venous access device exit site infections e. Fever of unknown origin f. Positive culture reports g. Signs and symptoms of two or more of the following: fever greater that 100.4 degrees Fahrenheit; elevated pulse rate; chills; sore throat; cough; malaise; nausea or vomiting; acute diarrhea; headache; dyspnea; rash; ulcer; pustule; drowsiness; confusion coma; localized tenderness, redness, erythema, or heat; urinary urgency, frequency, or dysuria; change in odor, color, consistency of drainage from wounds; any of the diseases from the list of reportable diseases. - When community-acquired or nosocomial infections are identified by the agency staff, they will be reported to the Director of Nursing and recorded on the Infection Control Log form. Nosocomial infections will also be reported to the health care facility’s infection control compliance person. - When infections are identified and reported on the infection Control Log, an investigation is conducted to determine possible causes. - Information from the Infection Control Log is reviewed on a quarterly basis to identify trends or patterns. The data is included in the monitoring and evaluation activities of the quality improvement committee or teams to identify opportunities to improve patient care and agency performance. - At least annually, the agency will review the results of this surveillance, monitoring, and evaluation and provide a report to the quality council, advisory board, and governing body of knowledge obtained, policy changes, or new procedures instituted. Review of the infection control and QAPI documents was conducted on 5/23/23. The agency failed to ensure the infection control data was complete; the quarterly infection control data was consistent with the individual infection report; the infection control data on each type of infection was analyzed and specific action plan implemented. For example: a. Review of the fourth quarter of 2019 infection control summary showed there were three cases of infection (two cases of respiratory/URI and one case of eye/ear/nose/throat). Review of the individual Infection Report showed two cases of respiratory and one case of GI/GT (Gastrointestinal/G-tube). * However, the type/site of infection documented in the individual Infection Report was inconsistent in the fourth quarter of 2019 infection control summary as there was no case of eye/ear/nose/throat included in the individual Infection Report. The fourth quarter of 2019 QAPI Meeting Minutes dated 1/6/20, showed there were three episodes of new infections and three cases of “ongoing infection control (chronic).” * However, there was no documented evidence of the infection control data related to the three cases of “ongoing infection control (chronic).” b. Review of the first, second, third, and fourth quarters of 2020 infection control summaries showed for urinary infection, there were three cases each for the first, second, and third quarters; and there were two cases for the fourth quarter. Documentation included the number of cases for “GI, Respiratory/URI, Eyes/ears/ nose/throat, Wound/Skin/Joint, Blood/Sepsis” for each quarter. The first, second, third, and fourth quarters of 2020 QAPI Meeting Minutes dated 4/6/20, 7/6/20, 10/5/20, and 1/11/21, respectively showed the number of cases for new and chronic infections for each quarter. Documentation showed the infection rate for each quarter on the new infections and whether the infection rate had increased, decreased, or remained the same. Documentation showed the recommendations/outcomes/follow-ups included to continue evaluation of infection report investigations for further prevention techniques; education to the staff and patient/PCGs on emerging COVID-19 pandemic/updates and policy changes; emphasize and encourage COVID-19 precautions; important infection control techniques/education from the CDC sent to the patient/PCGs and all staff; continued surveillance of both patient and employee infections; and the DPCS and RN Supervisor to monitor observe staff periodically to ensure COVID-19 P&P was followed. * However, the agency only analyzed the total number of new infections per quarter. There was no documented evidence the agency had analyzed each type of infection whether it had increased or decreased; and implemented specific action plan. c. Review of the first, second, third, and fourth quarters of 2022 infection control summaries showed for urinary infection, there were two cases in the first quarter, four cases in the second quarter, three cases in the third quarter, and five cases in the fourth quarter. Documentation also included the number of cases for “GI, Respiratory/URI, Eyes/ears/ nose/throat, Wound/Skin/Joint, Blood/Sepsis” for each quarter. The first, second, third, and fourth quarters of 2022 QAPI Meeting Minutes dated 4/11/22, 7/11/22, "1/9/23", and 1/9/23, respectively showed the cases of new and chronic infections for each quarter. Documentation showed the infection rate for each quarter on the new infections and whether the infection rate had increased, decreased, or remained the same. Documentation showed for recommendations/outcomes/follow-ups included to continue evaluation of infection report investigations for further prevention techniques; education to staff and patient/PCGs on upsurge of COVID-19 cases/ongoing COVID-19 pandemic/continuing COVID 19 precautions; emphasize and encourage COVID-19 precautions; important infection control techniques/education from CDC sent to patient/PCGs and all staff; continued surveillance of both patient and employee infections; and the DPCS and RN Supervisor to monitor observe staff periodically to ensure COVID-19 P&P was followed. * However, the agency only analyzed the total number of new infections per quarter. There was no documented evidence showing the agency had analyzed based on the type of infection if it had increased or decrease to identify trends or patterns; and implemented specific action plan. On 5/25/23 at 1029 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their COVID-19 P&P included the process by which staff may request an exemption from the COVID-19 vaccination requirements. This failure created the risk of not meeting the health and safety needs of the patient population and staff. Findings: Review of the QSO-22-07 showed the HHA’s P&Ps must include, at a minimum, a process for ensuring all staff have received, at a minimum, a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on applicable Federal law. Review of the agency’s P&P for COVID-19 was conducted on 3/23/23. However, there was no documented evidence the P&P included the process by which staff may request an exemption from the staff COVID-19 vaccination requirements. On 5/23/23 at 1348 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the finding.

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 agency failed to ensure the SN provided care and services in accordance with the POC for three of seven sampled patients (Patients 5, 6, and 7), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 7's closed clinical record was initiated on 5/22/23. The clinical record showed the SOC was 7/19/22. The patient was certified for home health services during the certification periods from 7/19/22 to 9/16/22, and 9/17/22 to 11/15/22. The POC, for the certification period from 7/19/22 to 9/16/22, showed LVN visits 240 hours/month and RN Supervisory visit one time a month according to Treatment Authorization Request as authorized by the “HCBA Waiver Program.” The POC included during the SN visit to monitor the patient’s pain and notify the physician for pain level above 9/10 pain on a scale of 0-10 (0 = no pain, 10 = worst pain) and significant changes in the patient’s condition. The POC showed SN to perform condom catheter care and management; and condom catheter can be changed QD and PRN for leaking, tears, and etc. The physician’s order dated 9/13/22, showed LVN shift care 0-240 hours/month or 1440 hours/180 days (1440 hours/180 days can be used per PCG’s discretion in situation where the patient would require more than 240 hors/ month), and RN supervisory visit one time a month according to the Treatment Authorization Record authorized by the “HCBA Waiver Program.” a. The TAR Response form dated 8/16/22, showed a quantity of 720 units from 7/19/22 to 10/16/22. A hand-written note showed 240 hours/month for LVN. * The SN visits showed the LVN had conducted 140 hours from 7/19/22 to 8/18/22 (one month) instead of 240 hours/month as per the POC. b. Some of the SN note showed the SN identified the patient had pain. However, there was no documented evidence of the pain level. For example * The SN note dated 7/27, 7/29, and 8/4/23, showed the patient had pain. However, there was no documented evidence of the patient’s pain levels. c. The Physician Order dated 7/19/22, showed to administer Keto functional formularies (tube feeding formula and meal replacement) one bag/240 ml three times daily at about six hours apart via G-tube. Documentation showed, “Water or juice. Give ad lib Via G-tube for hydration.” * Some the SN notes showed the type of feeding formula administered was not consistent with the POC. For example: - The SN note dated 7/27/23 (0800 hours-1800 hours), showed Ensure Plus (nutritional shake/drink) was administered at 1000 hours, and Ensure was administered at 1600 hours, instead of Keto functional formularies. - The SN note dated 8/4/22 (0800 hours -1800 hours), showed “peptide high protein formula was administered at 0800 and 1400 hours, and Ensure was administered at 1000 hours instead of Keto functional formularies. - The SN note dated 9/10/23 (0800 hours -1800 hours), showed “keto organic formula” was administered at 0800 hours, “compleat ensure” was administered at 1200 hours and “peptide formula was administered” at 1400 hours instead of Keto functional formularies.. * Some of the SN notes showed the amount of tube feeding formula administered was not consistent with the POC. For example: - The SN note dated 7/30/22 (0800 hours-1800 hours), showed at 0800 and 1400 hours, 400 ml of Keto organic formula was administered instead of 240 ml. - The SN note dated 8/5/22 (0800 hours -1800 hours), showed 350 ml of Keto organic formula was administered at 0800 and 1400 hours instead of 240 ml. d. The SN note dated 8/6/24, showed the patient utilized four condoms. Documentation showed the condom kept coming out due to small amount of Neosporin (topical antibiotic) ointment applied the upper part of the penis due to suspected abrasion. However, there was no documented evidence of a physician’s order for the use of Neosporin ointment. e. The physician’s order dated 7/19/22, showed the patient was to be on ventilator for 24 hours daily. The POC showed the ventilator settings included high pressure alarm of 50 and low pressure alarm of 10. The Ventilation Record showed the following information related to the high pressure alarm and low pressure alarm: - On 7/27, 7/28, 7/29, 8/3 ,8/4, 8/5, and 8/6/22, showed the high pressure alarm was 21 and low pressure alarm was 7. - On 8/17, 8/18, 8/19, 8/20, 8/24, 8/25, 8/26, and 8/27/22, showed the high pressure alarm was 10 and low pressure alarm was blank. * However, the above values of the high pressure and low pressure alarm were not consistent with the POC. On 5/25/23 at 1022 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23. The POC, for the certification period from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23, showed the following information: - Ketocal (medical food) 4:1 liquid three cans daily, give one can at 60 ml/hour via G-tube three times a day. Documentation showed to flush G-tube with 90 ml water before and after G-tube feedings. - SN to change tracheostomy ties QD and PRN when soiled or soaked; and SN to change inner cannula of tracheostomy Q morning. - SN will perform G-tube care QD and PRN. a. The SN notes for the certification period from 3/14/23 to 5/12/23, and SN notes dated 5/13, 5/14, and 5/15/23, showed the SN did not provide the patient with 90 ml water before and after G-tube feedings as per the POC. For example: The SN note dated 3/18/23, showed at 0900 hours, Ketocal was administered and 50 ml of water was provided; and at 1500 hours, Ketocal was administered and 50 ml of water was provided instead of 90 ml of water before and after G-tube feedings as per the POC. The SN note dated 5/13/23, showed at 0700 hours, Ketocal was administered and 90 ml of water was provided; and at 1400 hours, Ketocal was administered and 90 ml of water was provided instead of 90 ml of water before and after G-tube feedings as per the POC. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. b. The Treatment Record, for the certification period from 3/14/23 to 5/12/23, showed not applicable was recorded for SN to change the tracheostomy ties QD and PRN when soiled or soaked; SN to change inner cannula of tracheostomy Q morning; and SN to perform G-tube care QD and PRN on 3/14, 3/15, 3/16,3/17, 3/18, 3/20, 3/21, 3/22, 3/23, 3/24, 3/25, 3/27, 3/28, 3/29, 3/30, 3/31, 4/1, 4/3, 4/4, 4/5, 4/6, 4/11, 4/12, 4/13, 4/14, 4/15, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/11, 5/12, and 5/13/23. The Treatment Record, for the certification period from 5/13/23 to 7/11/23, showed not applicable was recorded for SN to change the tracheostomy ties QD and PRN when soiled or soaked; SN to change inner cannula of tracheostomy Q morning; and SN to perform G-tube care QD and PRN on 5/14, 5/15, 5/16, and 5/17/23. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and the RN Supervisor. They were informed and acknowledged the finding. 3. Review of Patient 6’s closed clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/16/20. The patient was certified for home health services during the certification periods from 5/9/22 to 7/7/22, and 7/8/22 to 9/5/22. The POC, for the certification period from 5/9/22 to 7/7/22, showed CHHA 0-240 hours/month or 0-1440 hours/180 days (1440hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 240 hours/month) and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by Medi-Cal Waiver Program. Review of the clinical record showed the CHHA visits were conducted, for the certification period from 5/9/22 to 7/7/22. * However, there was no documented evidence of a RN supervisory visit as per the POC. On 5/23/23 at 1250 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for two of seven sampled patients (Patients 5 and 7), creating the increased risk of substandard healthcare outcomes to these patients. Findings: 1. Review of Patient 7's closed clinical record was initiated on 5/22/23. The clinical record showed the SOC was 7/19/22. The patient was certified for home health services during the certification periods from 7/19/22 to 9/16/22, and 9/17/22 to 11/15/22. a. The SN note dated 7/28/22, showed the patient did not have pain. However, another section of the note showed the patient had stomach pain and the family member called the physician regarding the pain. b. The SN note dated 8/6/22, showed the patient utilized four condoms. Documentation showed the condom kept coming out due to small amount of Neosporin ointment (topical antibiotic) applied the upper part of the penis due to suspected abrasion. The treatment record dated 8/6/22, showed the physician was notified of the significant condition. The SN note dated 8/19/22, showed the patient’s BP was 195/66 mmHg; and the treatment record dated 8/19/22, showed the physician was notified for the BP above 160/90 mmHg. * However, there was no documented evidence of the physician’s responses to the notification on 8/6 and 8/19/22. On 5/25/23 at 1022 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23. The POC, for the certification period from 3/14/23 to 5/12/23, showed SN to reposition the patient Q two hours or PRN Q shift. The SN notes dated 3/27, 3/28, 3/29, 3/30, and 3/31/23, showed the SN conducted the visit from 0700 hours to 1500 hours. * However, the Treatment Record dated 3/27, 3/28, 3/29, 3/30, and 3/31/23, showed the patient was repositioned at 1700 hours, which was inconsistent with the time of the SN’s visits. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the RN provided supervision to the LVN to ensure quality of care and services were provided as per the agency's P&P for one of seven sampled patients (Patient 5), creating the risk for a substandard healthcare outcome to this patient. Findings: Review of the agency’s P&P titled Supervision of Staff dated 3/30/20, showed all staff providing home care services will be supervised as outline by federal and state regulations and accepted standards of practice. When patients are receiving skilled nursing services in addition to personal care, the RN will make a supervisory visit to the patient’s residences at least Q two weeks. If patients are receiving only home health aide services and there is no skilled services provided, a RN will make supervisory visit while the aide is providing care at least once Q sixty days, or per the State/agency guidelines. 1. Review of Patient 5’s clinical record was initiated on 5/16/23. The clinical record showed the SOC was 3/14/23. The patient was certified for home health services during the certification periods from 3/14/23 to 5/12/23, and 5/13/23 to 7/11/23. The SN notes showed the LVN failed to provide care and services related to water administration before and after G-tube feeding, trach tie changes, and change of inner cannula as per the POC . Cross reference to G710, example #2. Further review of the clinical record showed the RN had conducted the LVN supervisory visits on dated 4/12 and 5/12/23, to ensure the LVN had had adhered to the plan of treatment. However, the RN failed to identify the LVN did not perform the tasks as cited in the POC. On 5/23/23 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

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 agency failed to ensure the written assignment for CHHA were consistently prepared by the RN for two of seven sampled patients (Patients 2 and 6), creating the risk of not providing the necessary care and services to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 10/11/22. The patient was certified for home health services during the certification period from 4/9/23 to 6/7/23. The POC, for the certification period from 4/9/23 to 6/7/23, cited CHHA shift care 0-240 hours/month or 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’ discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by the” HCBA Waiver Program.” The POC included CHHA to perform PROM exercises to the extremities or massages Q shift. * However, the Home Health Aide Assignment dated 4/4/23, showed to perform passive and active ROM exercises Q visit, which was not consistent with the POC. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 6’s closed clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/16/20. The patient was certified for home health services during the certification periods from 5/9/22 to 7/7/22, and 7/8/22 to 9/5/22. The POC, for the certification period from 5/9/22 to 7/7/22, showed CHHA 0-240 hours/month or 0-1440 hours/180 days (1440hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the treatment authorization request authorized by Medi-Cal Waiver Program. The POC included CHHA to perform passive ROM exercise Q day to the extremities as tolerated by the patient. However, the Home Health Aide Assignment dated 5/13/22, showed to perform active/passive ROM exercises Q visit, which was not consistent with the POC. On 5/23/23 at 1250 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the CHHAs provided care and services in accordance with the POC for three of seven sampled patients (Patients 2, 3, and 6), creating the risk of not providing necessary care and services to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 10/11/22. The patient was certified for home health services during the certification period from 4/9/23 to 6/7/23. The POC, for the certification period from 4/9/23 to 6/7/23, cited CHHA shift care 0-240 hours/month or 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’ discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by the” HCBA Waiver Program.” The POC included during CHHA visits, to take vital signs, provide bed bath PRN, provide assistance with personal care including medication reminder, provide peri care with diaper changes, provide assistance with meal preparation and feedings, provide ADL and personal care as needed, perform PROM exercises to the extremities or massages Q shift, reposition the patient Q two hours and PRN, provide safe transfers, provide linen changes and light housekeeping PRN, perform care using universal and safety precautions, and to notify supervisor if the patient had discoloration, swelling, bruises, increased pain, decreased mobility, new wound, and decreased appetite. The Home Health Aide Assignment dated 4/4/23, showed the following task assignments: vital signs, perineal care, skin care, foot care, mouth care, passive/active ROM exercises, turn and reposition, up in wheelchair, transfer from bed to chair, dressing activity, prepare meal/snack Q visit; tub, shower, sponge, complete bed bath, partial bed bath, shampoo, grocery, bed linen change, personal laundry, light housekeeping PRN; lotion back rub per patient request; and diaper changes Q visit and PRN. a. Some of the CHHA notes failed to show documented evidence the CHHA obtained the vital signs as per the POC and Home Health Aide Assignment. For example: The CHHA note dated 4/11/23 (1601 hours–2001 hours), showed no documented evidence the patient’s pulse rate and respiration were obtained. The CHHA note dated 4/15/23 (0800 hours-1800 hours), showed no documented evidence the patient’s temperature and respiration were obtained. The CHHA note dated 4/25/23 (1601 hours-2001 hours), showed no documented evidence the patient’s vital signs (temperature, BP, pulse rate and respiration) were obtained. b. Some of the CHHA notes showed the CHHA performed nail hygiene (clean/file/report), exercise as per the PT/OT/SLP Care Plan, inspect reinforce dressing, and ambulation assist (wheelchair/walker/cane) was completed. However, the above tasks were not included in the POC and Home Health Aide Assignment. For example: The CHHA note dated 4/10/23 (1601 hours-2000 hours), showed nail hygiene and ambulation assist were completed, which were not consistent with the POC and Home Health Aide Assignment. The CHHA note dated 4/11/23 (1601 hours-2001 hours), showed nail hygiene, inspect/reinforce dressing, ambulation assist, and exercise per PT/OT/SLP Care Plan) were completed, which were not consistent with the POC and Home Health Aide Assignment. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23. a. The POC, for the certification period from 2/11/23 to 4/11/23 and 4/12/23 to 6/10/23, cited CHHA shift care 0-240 hours/month, 0-1440 hours/180 days (1440 hours/180 days can be used per PCG’s discretion in situations where patient requires more than 240 hours/month), and RN supervisory visit Q two weeks according to Treatment Authorization Request authorized by Medi-Cal Waiver Program. The POC included during CHHA visits, to take vital signs Q visit, provide assistance with tub/shower/bed bath (partial sponge or complete) PRN, provide assistance with personal care including medication reminder, eating assistance, skin care, mouth care and peri care, apply condom catheter PRN when going to physician/medical appointments, provide assistance with meal preparation and feedings, provide assistance with linen changes, emptying trash, and light housekeeping perform care using universal and safety precautions, perform PROM exercises to extremities as tolerated by patient, monitor urine on diaper for sign/symptoms of infection, and to notify supervisor if the patient has discoloration, swelling, bruises, increased pain, decreased mobility, new wound, and decreased appetite. The Home Health Aide Assignment dated 2/6/23, showed the following task assignments: vital signs, perineal care, skin care, foot care, mouth care, passive ROM, turn and reposition, up in wheelchair, transfer from bed to chair, dressing activity, toilet/bedpan/commode, prepare meal/snack, oral feeding, bed linen change, personal laundry, light housekeeping Q visit; shower, sponge, complete bed bath, partial bed bath, shampoo, and lotion back rub PRN. * The CHHA note dated 4/5/23, showed no documented evidence the patient’s BP and pulse rate were obtained as per the POC and Home Health Aide Assignment. * Some of the CHHA notes showed the CHHA performed nail hygiene (clean/file/report), exercise per the PT/OT/SLP Care Plan, inspect/reinforce dressing, ostomy care, and ambulation assist (wheelchair/walker/cane). However, the above tasks were not included in the POC and Home Health Aide Assignment. For example: The CHHA note dated 2/11/23 (1430 hours-2000 hours), showed nail hygiene, ostomy care, inspect reinforce dressing, exercise as per the PT/OT/SLP Care Plan, and ambulation assist were completed, which were not consistent with the POC and Home Health Aide Assignment. The CHHA notes dated 2/12/23 (1500 hours -1930 hours) and 3/9/23 (0900 hours-1700 hours), showed nail hygiene, ambulation assist, and exercise as per the PT/OT/SLP Care Plan were completed, which were not consistent with the POC and Home Health Aide Assignment. The CHHA note dated 3/23/23 (0900 hours-1700 hours), showed nail hygiene, inspect/reinforce dressing, and ambulation assist were completed, which were not consistent with the POC and Home Health Aide Assignment. On 5/25/23 at 0958 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 3. Review of Patient 6’s closed clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/16/20. The patient was certified for home health services during the certification periods from 5/9/22 to 7/7/22, and 7/8/22 to 9/5/22. The POC, for the certification period from 5/9/22 to 7/7/22, showed during CHHA visits, the CHHA to take vital signs, provide assistance with bathing/shower PRN, provide assistance with personal care including medication reminders, eating assistance, skin care, mouth care, and peri care, provide assistance with meal preparation and feedings, provide assistance with reposition changes and turning Q two hours and PRN, perform care using universal and safety precautions, passive ROM Q day to extremities as tolerated by patient, provide safe environment and safe transfers, provide assistance with linen changes, emptying trash, and light housekeeping, and to notify the supervisor if the patient had discoloration, swelling, bruises, increased pain, decreased mobility, new wound, seizures, and decreased appetite. The Home Health Aide Assignment dated 5/13/22, showed the following task assignments: vital signs, shower, sponge, complete bed bath, partial bed bath, perineal care, skin care, foot care, mouth care, shampoo, and lotion back rub, ambulate (cane/walker/crutches/steps/stair climbing/yard walking),active/passive ROM exercises, turn and reposition, up in wheelchair, transfer from bed to chair, dressing activity, med reminders, toilet/bedpan/commode, prepare meal/snack, oral feeding, bed linen change, personal laundry, and light housekeeping Q visit. The CHHA notes for the certification period 5/9/22 to 7/7/22, showed the CHHA failed to follow the POC. For example: - The CHHA note date 5/13/22, showed no documented evidence the patient’s ROM and positioning were completed. - The CHHA note dated 5/15/23, showed no documented evidence the patient’s respiratory rate and pulse rate were obtained; and the ROM exercises and positioning were completed. On 5/23/23 at 1250 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the CHHA reported changes in the patient’s condition to a registered nurse or other appropriate skilled professional for one of seven sampled patients (Patient 3), creating the risk of not providing necessary care and services to this patient. Findings: Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23. The POCs, for the certification period from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23, cited CHHA shift care 0-240 hours/month, 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by Medi-Cal Waiver Program. The POC showed the CHHA to notify the supervisor if the patient had discoloration, swelling, bruises, increased pain, decreased mobility, new wound, and decreased appetite. a. The CHHA note dated 4/27/23 (1701 hours-2001 hours), showed there was a “New/Changed Pain.” Documentation showed the pain level of 6. The CHHA notes dated 5/4/22 (1700 hours-2000 hours) and 5/6/22 (1700 hours-2000 hours), showed there was a “New/Changed Pain.” Documentation showed the pain level of 6 for shoulder pain. The CHHA note dated 5/7/22 (1701 hours-2001 hours), showed there was a “New/Changed Pain.” Documentation showed the pain scale of 5 for the left arm pain. * However, there was no documented evidence the Supervisor was notified of “New/Changed Pain.” b. The CHHA note dated 5/6/23 (0900 hours-1700 hours), showed the patient’s respiration was 29 breath per minute. * However, there was no documented evidence the RN was notified of the patient’s respiration of 29 breath per minute. On 5/25/23 at 0958 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's RN provided supervision to the CHHA to ensure quality of care and services provided for two of seven sampled patients (Patients 2 and 3), creating the increased risk of providing substandard healthcare to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 10/11/22. The patient was certified for home health services during the certification period from 4/9/23 to 6/7/23. The POC, for the certification period from 4/9/23 to 6/7/23, cited CHHA shift care 0-240 hours/month or 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’ discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by the” HCBA Waiver Program.” The POC included CHHA to take vital signs, provide bed bath PRN, provide assistance with personal care including medication reminder, provide peri care with diaper changes, provide assistance with the meal preparation and feedings, provide ADL and personal care as needed, perform PROM exercises to extremities or massages Q shift, reposition patient Q two hours and PRN, provide safe transfers, provide linen changes and light housekeeping PRN, perform care using universal and safety precautions, and to notify supervisor if the patient has discoloration, swelling, bruises, increased pain, decreased mobility, new wound, and decreased appetite. The Home Health Aide Assignment dated 4/4/23, showed the following task assignments: vital signs, perineal care, skin care, foot care, mouth care, passive/active ROM, turn and reposition, up in wheelchair, transfer bed to chair, dressing activity, prepare meal/snack Q visit; tub, shower, sponge, complete bed bath, partial bed bath, shampoo, grocery, bed linen change, personal laundry, light housekeeping PRN; lotion back rub per patient request; and diaper changes Q visit and PRN. The CHHA notes showed the CHHA failed to provide care and services in accordance with the POC. Cross reference to G800, example # 1. Further review of the clinical record showed the RN had conducted the CHHA supervisory visits on 4/22/23 and 5/6/23, to ensure the CHHA had followed the POC. However, the RN failed to identify the CHHA did not perform the tasks as cited in the POC. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23. The POC, for the certification periods from 2/11/23 to 4/11/23 and 4/12/23 to 6/10/23, cited CHHA shift care 0-240 hours/month, 0-1440 hours/180 days (1440 hours/180 days can be used per PCG’s discretion in situations where patient requires more than 240 hours/month), and RN supervisory visit Q two weeks according to Treatment Authorization Request authorized by Medi-Cal Waiver Program. The POC included during the CHHA visits to take vital signs Q visit, provide assistance with tub/shower/bed bath (partial sponge or complete) PRN, provide assistance with personal care including medication reminder, eating assistance, skin care, mouth care and peri care, apply condom catheter PRN when going to MD/medical appointments, provide assistance with meal preparation and feedings, provide assistance with linen changes, emptying trash, and light housekeeping, perform care using universal and safety precautions, perform PROM exercises to extremities as tolerated by patient, monitor urine on diaper for sign/symptoms of infection, and to notify supervisor if the patient has discoloration, swelling, bruises, increased pain, decreased mobility, new wound, and decreased appetite. The Home Health Aide Assignment dated 2/6/23, showed the following task assignments: vital signs, perineal care, skin care, foot care, mouth care, passive ROM, turn and reposition, up in wheelchair, transfer bed to chair, dressing activity, toilet/bedpan/commode, prepare meal/snack, oral feeding, bed linen change, personal laundry, light housekeeping Q visit; shower, sponge, complete bed bath, partial bed bath, shampoo, and lotion back rub PRN. The CHHA notes showed the CHHA failed to provide care and services in accordance with the POC. Cross reference to G800, example #2. Further review of the clinical record showed the RN had conducted the CHHA supervisory visits on 2/24, 3/10, 3/24, and 4/7/23, to ensure the CHHA had followed the POC. However, the RN failed to identify the CHHA did not perform the tasks as cited in the POC. On 5/25/23 at 0958 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency's Administrator failed to ensure the responsibility for the day-to-day operations of the agency as follows: * The agency failed to ensure two employee files reviewed (LVN1 and CHHA 2) had their health assessments completed in a timely manner. * The agency failed to ensure the written agreements for two contractors (Contractors 1 and 2) included the required elements as per the state regulations, Title 22. These failures had the potential to negatively impact the agency’s operational performance. Findings: The agency’s P&P titled Job Description: "Administration" showed the essential functions include to plan, organize, and direct the agency’s ongoing functions and ensure compliance with Federal and State regulations governing home health care service through policy and procedure administration. 1. According to Title 22 Section 74723 (b)(2), a written health assessment of each employee who has direct patient contact shall be performed within six months prior to employment or within 15 days of assuming employment with the agency. The agency’s P&P titled Health Screening dated 1/19/18, showed each employee having direct contact with the patients must have documentation of baseline health screening prior to providing care to patients. This includes at a minimum TB skin testing via Mantoux method. This testing includes the preplacement evaluation, administration, and interpretation of TB Mantoux skin test and periodic evaluation. On any employee or contract personnel providing direct patient care, there shall be documentation of completion of annual tuberculin skin test, via the Mantoux method. Review of the employee files conducted on 5/23/23, showed the following: - CHHA 2 was hired on 2/15/23. However, the employee’s health assessment was completed on 3/23/23, more than 15 days of assuming employment with the agency. In addition, there was no documented evidence of a TB screening. - LVN 1 was hired on 3/14/23. However, the employee’s health assessment was completed on 5/18/23, more than 15 days of assuming employment with the agency. On 5/23/23 at 1341 hours, an interview and concurrent clinical record review was conducted with the RN Supervisor. She was informed and acknowledged the findings. 2. According to Title 22 Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the following: the nature and scope of services to be provided; the rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; and the role, if any, of the agency and the contracted individual or agency in the patient admission process, patient assessment, the development, review, and revision of the plan of treatment or plan of care, patient care conferences, the scheduling of visits or hours, discharge planning, the submission to the agency of documentation of services provided, and the responsibility of the contractor to applicable agency policies including personnel qualifications. a. Review of the written agreements between the agency and Contractors 1 and 2 was initiated on 5/23/23. The written agreements did not include the following requirements: - The role, if any, of the agency and the contractors in the patient admission process. - The role, if any, of the agency and the contractors in patient assessments. - The role, if any, of the agency and the contractors in the patient care conferences. - The role, if any, of the agency and the contractors in the scheduling of visits or hours. - The role, if any, of the agency and the contractors in the discharge planning. b. Review of the written agreement between the agency and Contractor 2 was initiated on 5/23/23. The written agreements did not include the rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of care and services provided. On 5/23/23 at 1328 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the interventions included in the clinical records were accurate and complete for two of seven sampled patients (Patients 2 and 3), creating the risk of substandard care provided to these patients as their clinical information were not accurate. Findings: 1. Review of Patient 2's clinical record was initiated on 5/18/23. The clinical record showed the SOC was 10/11/22. The patient was certified for home health services during the certification period from 4/9/23 to 6/7/23. The POC, for the certification period from 4/9/23 to 6/7/23, cited CHHA shift care 0-240 hours/month or 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’ discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by the” HCBA Waiver Program.” The POC included to notify the supervisor if the patient had discoloration, swelling, bruises, increased pain, decreased mobility, new wound, and decreased appetite. * Review of the CHHA notes showed some notes were incomplete. For example: The CHHA notes dated 4/10/23 (0800 hours -1600 hours and 1401 hours-2000 hours) and 4/12/23 (0800 hours-1600 hours), showed the section which asked if the patient had new/changed pain was not completed. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 5/16/23. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services during the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23. The POCs, for the certification periods from 2/11/23 to 4/11/23, and 4/12/23 to 6/10/23, cited CHHA shift care 0-240 hours/month, 0-1440 hours/180 days (1440 hours/180 days can be used per the PCG’s discretion in situations where the patient would require more than 240 hours/month), and RN supervisory visit Q two weeks according to the Treatment Authorization Request authorized by Medi-Cal Waiver Program. * Some of the CHHA notes showed, “Limit/Encourage Fluids” was completed. However, there was no documented evidence showing what specifically performed. On 5/25/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge summary was completed for two of seven sampled patients (Patients 6 and 7). This failure created the risk of providing substandard care to these patients as their clinical information were not completed. Findings: 1. Review of Patient 7's closed clinical record was initiated on 5/22/23. The clinical record showed the SOC was 7/19/22. The patient was certified for home health services during the certification periods from 7/19/22 to 9/16/22, and 9/17/22 to 11/15/22. The Discharge Summary dated 9/28/22, showed the patient was transferred to another HHA. However, the completed discharge summary failed to show documented evidence the date when the summary was faxed or sent to the physician. In addition, there was no documented evidence, the discharge summary included the medications that the patient was on at the time of discharge, patient outcomes in meeting the goals in the plan of care, and the patient and family post-discharge instructions. On 5/25/23 at 1022 hours, an interview and concurrent clinical record review was conducted with the CEO, Administrator, DPCS, and RN Supervisor. They were informed and acknowledged the findings. 2. Review of Patient 6’s closed clinical record was initiated on 5/16/23. The clinical record showed the SOC was 9/16/20. The patient was certified for home health services during the certification periods from 5/9/22 to 7/7/22, and 7/8/22 to 9/5/22. The Discharge Summary dated 8/2/22, showed the patient was discharged on 8/2/22. However, the completed discharge summary showed no documented evidence the discharge summary included the medications that the patient was on at the time of discharge. In addition, the documentation showed not applicable was documented under the patient’s condition at discharge. On 5/23/23 at 1250 hours, an interview and concurrent clinical record review was conducted with the DPCS and RN Supervisor. They were informed and acknowledged the findings.