Every finding on record at Grapevine Home Health Services, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation survey conducted August 9, 2021 through August 12, 2021. Representing the Department: Surveyors: 35183 42896 Census: 471 Unduplicated Admissions: 2480 Home Visits with record reviews: 4 Record Reviews without home visits: 4 Sample Size: 8 Two complaints were investigated during the Complaint Validation survey: CA00704084: Substantiated, 3 deficiencies were issued (Refer to G 480, G 572 and G 966) CA00723309: Substantiated, 2 deficiencies were issued (Refer to G 550 and G 572) The following Conditions of Participation were not met: G 510 484.55 Comprehensive Assessment Of Patients G 570 484.60 Care Planning, Coordination, Quality Of Care G 940 484.105 Organization And Administration Of Services

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to investigate a complaint of failure to provide Physical Therapy (PT) services to meet patient goals, for one of eight sampled patients (Patient 4). This failure caused Patient 4 to lose physical therapy services before achieving optimal physical functioning. Findings: A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of August 4, 2020, with a certification period of August 4, 2020 to October 2, 2020. Patient 4 had diagnoses that included fracture (break) of the left femur (thighbone). During an interview with Patient 4's Primary Caregiver (PCG) on September 17, 2020, the PCG stated the family requested home health for Patient 4 after hip surgery. The PCG stated when Patient 4 first came home he required maximum assistance to get in and out of the car. The PCG stated Patient 4 was given four physical therapy visits. The PCG stated she requested more physical therapy visits for Patient 4. The PCG stated the Physical Therapist (PT) told her he would request more visits. The PCG stated when she followed up with PT, he stated the case manager had discharged Patient 4 from physical therapy. The PCG stated there was no follow up and the Primary Physician was not notified. The PCG stated she felt the Primary Physician would have authorized more PT visits if he had been consulted. A review of Patient 4's physician's order dated August 4, 2020 indicated, "Approved for: (4) [four] ... Physical Therapy [visits]." A review of Patient 4's "Physical Therapy Discharge Summary," dated August 18, 2020 indicated the following: "Reason for Discharge: ...end of auth [authorized] visits. Goals Achieved: Patient/caregiver demonstrated knowledge of health care teaching ...Partially Met Patient/caregiver demonstrated independence in ADLs [activities of daily living]/IADLs [instrumental activities of daily living] ...Partially Met Patient/caregiver demonstrated knowledge in disease process, medication, diet, safety/standard precautions ...Partially Met Patient attained an optimal level of function/independence ...Partially Met Patient demonstrated stable physiological condition ...Partially Met Patient received assistance with personal and ADL mgmt. [management] ...Partially Met" A review of a "Communication Note," dated September 4, 2020 by a Licensed Vocational Nurse Case Manager (LVNCM 1) indicated, "[Name of LVNCM 1] received a call from the [Patient 4's] daughter at 1420 [2:20 PM]. Patient's daughter asked about additional PT [Physical Therapy]. [Name of LVNCM 1] confirmed understanding and informed the patient's daughter that [name of agency] received signed PT notes but the MD [Medical Doctor] did not send an order for additional physical therapy. Patient's daughter confirmed understanding and requested her father be discharged from all Home Health Services at this time. [Name of LVNCM 1] confirmed understanding. MD notified." During an interview with LVNCM 1 on August 10, 2021 at 3:01 PM, LVNCM 1 stated, "Yes, the daughter was unhappy with the process of getting more PT visits and that we did not get additional PT visits for her father." LVNCM 1 stated the daughter did not want to continue to do business with the agency so she requested her father to be discharged and transferred to another agency. LVNCM 1 stated he had talked to the Administrator/Director of Patient Care Services (Admin/DPCS) about the daughter being upset about the PT visits. LVNCM 1 stated he told the Admin/DPCS Patient 4's daughter requested a transfer to a different home health agency. LVNCM 1 stated he did not fill out a complaint form on this incident. LVNCM 1 stated he was not aware of the complaint process to follow at the agency. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 10:25 AM, the Admin/DPCS stated LVNCM 1 had not reported that Patient 4's daughter was upset with the services and lack of services the agency provided. The Admin/DPCS stated LVNCM 1 had not reported Patient 4's daughter had discharged/transferred her father to another home health agency. The Admin/DPCS stated LVNCM 1 should have reported the complaint to her so it could be investigated. The Admin/DPCS stated, "I might have been able to keep this patient on services, if I had known." A review of the agency's policy and procedure titled, "Complaint/Grievance," undated, indicated the following: "Purpose: To set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. Policy: Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and [name of agency] concerning any aspect of services or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations, and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Bill of Rights document given to each patient upon admission. The organization will investigate complaints regarding treatment or care... Procedure: The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt... Complaints and any action taken will be documented on a complaint form... All complaints will be logged, tracked, trended, and filed in the performance improvement office... All organization personnel (clinical and non-clinical) will be informed of this process during a formal orientation process..."

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: The agency failed to ensure the Condition of Participation: G 510 484.55 Comprehensive Assessment of Patients was in compliance when: 1. Based on interview and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for three of eight sampled patients (Patients 2, 5, and 6) when: a. For Patient 2: a Medication Profile (MP-a current list of all medications prescribed for a specific patient), was never created. (Refer to G 536) b. For Patient 5: one medication the patient was taking was not indicated on the MP and one medication the patient was not taking was indicated on the MP. (Refer to G 536) c. For Patient 6: three medications the patient was not taking were indicated on the MP. (Refer to G 536) 2. Based on interview and record review, the agency failed to ensure the comprehensive assessment was updated by a discharge assessment and summary for three of eight sampled patients (Patients 1, 2 and 3). (Refer to G 550) The cumulative effect of these systemic practices resulted in the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. And the patients to loose services before a resolution of: shortness of breath, pain, wounds and muscle weakness.

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 interview and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for three of eight sampled patients (Patients 2, 5, and 6) when: 1. For Patient 2: a Medication Profile (MP-a current list of all medications prescribed for a specific patient), was never created. 2. For Patient 5: one medication the patient was taking was not indicated on the MP and one medication the patient was not taking was indicated on the MP 3. For Patient 6: three medications the patient was not taking were indicated on the MP This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: 1. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 7, 2020, with a certification period of December 7, 2020 to February 5, 2021. Patient 2 had diagnoses that included COVID 19 (coronavirus) infection. A review of Patient 2's Plan of Care (POC) dated December 7, 2020 to February 4, 2021 was conducted. There was no documented evidence to show medications for Patient 2. A review of Patient 2's Medication Profile (MP), undated, was conducted. Patient 2's MP was blank. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:15 AM, the Admin/DPCS stated she had conducted Patient 2's admission assessment and was responsible for creating the POC and MP. The Admin/DPCS stated the POC had not been created so no medications were listed. The Admin/DPCS verified that Patient 2's MP was blank. The Admin/DPCS stated, "Everything seemed to have gotten missed with this patient and I don't know why." 2. A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 5 had diagnoses that included Chronic Kidney Disease (kidney loses filtering ability). Patient 5 had a start of care on June 14, 2021, with a certification period of June 14, 2021 to August 12, 2021. During a home visit on August 10, 2021 with Licensed Vocational Nurse (LVN 5) and in the presence of Patient 5 and Patient 5's husband, an observation of Patient 5's actual medication bottles available in the home were compared with Patient 5's most current Medication Profile (MP). During a concurrent observation and interview on August 10, 2021, at 8:35 AM, with LVN 5, LVN 5 checked a bottle of Vitamin D-3 (supplement) 25mcg (microgram-a unit of measure) 1,000iu (unit of measure), one tablet by mouth daily. Patient 5's MP has no indication of the order of Vitamin D-3 25mcg 1,000iu one tablet by mouth daily. LVN 5 verified Patient 5's bottle of Vitamin D-3 has no record on MP. During an interview on August 10, 2021, at 8:40 AM, with Patient 5, Patient 5 stated, "I've been taking Vitamin D-3 a couple of months ago. I took it in the beginning of starting home health. My doctor is aware of it." A continued interview on August 10, 2021, at 8:40 AM, with Patient 5, Patient 5 stated, "I don't take Amlodipine (high blood pressure medication). I've only taken Atenolol (high blood pressure medication), Amiodarone (medication for abnormal heart rhythm) and Warfarin (blood thinner medication)." During a concurrent observation and interview on August 10, 2021, at 8:45 AM, with LVN 5, LVN 5 verified that another Amlodipine 200 mg (milligram-a unit of measure) 1 tablet by mouth was listed in the MP that Patient 5 does not take. During an interview on August 10, 2021, at 3:00 PM, with Registered Nurse (RN 1), RN 1 stated, "Vitamin D-3 was missed that's why it's not on the list." A continued interview on August 12, 2021, at 9:30 AM, with Licensed Vocational Nurse Case Manager (LVNCM 3), LVNCM 3 stated, "Case Manager is responsible for inputting and updating Medication Profile." LVNCM 3 verified there's a duplicate Amlodipine 200 mg 1 tablet by mouth daily was listed in the MP. LVNCM 3 stated, "It was not updated as it should be." During an interview on August 12, 2021, at 11:15 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, "It was Case Manager's responsibility to update Medication Profile when there's any new order or changes. Nurses should have been reviewing and updating medication profile on their visits." 3. A review of the Patient 6's Plan of Care (POC) with a certification period of July 17, 2021 to September 14, 2021, indicated Patient 6 had diagnoses that included Cellulitis (bacterial skin infection). Patient 6 had a start of care on July 17, 2021. During a home visit on August 10, 2021 with Licensed Vocational Nurse (LVN 6) and in the presence of Patient 6 and Patient 6's daughter, an observation of Patient 6's actual medication bottles available in the home were compared with Patient 6's most current Medication Profile (MP). During a concurrent observation and interview on August 10, 2021, at 10: 10 AM, with LVN 6, LVN 6 stated, "Patient 6 stopped taking Fenofibrate (cholesterol medication) 145 mg (milligram-a unit of measure) tablet, take 1 tablet by mouth daily, Clopidogrel (blood thinner medication) 75 mg tablet, take 1 tablet by mouth daily and Oxycodone (a type of opioid pain medication containing acetaminophen) 10/325 mg tablet, take 1 tablet by mouth every 4 (four) hours for pain two weeks ago after coming back from the hospital. The printed MP should have been updated." During an interview on August 10, 2021, at 10:20 AM, with Patient 6, Patient 6 stated, "I stopped taking Oxycodone routine, Fenofibrate and Clopidogrel two weeks ago after coming back from the hospital." During an interview on August 12, 2021, at 9:45 AM, with Licensed Vocational Nurse Case Manager (LVNCM 4), LVNCM 4 stated, "When Patient 6 went to the hospital, the system did not update the Medication Profile. It's the Case Manager responsibility to update." During an interview on August 12, 2021, at 11:15 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, "It was Case Manager's responsibility to update Medication Profile when there's any new order or changes. Nurses should have been reviewing and updating medication profile on their visits." A review of the agency's policy and procedure titled "Initial and Comprehensive Assessment," undated, indicated the following: "Policy: ... Prior to completion of a comprehensive assessment by a therapist, a registered nurse or qualified clinician must conduct a Drug Regimen Review. Procedure: ... Review of medication history, as applicable to care and service and current medication use, including prescription, over-the-counter medications and herbal medications, and identifying drug interactions, duplicative drug therapy, potential adverse effects and drug reactions, ineffective drug therapy, significant side effects and noncompliance with therapy." A review of the agency's policy and procedure titled, "Medication Profile," dated December 2018, indicated the following: "Purpose: To define the use of the medication profile in evaluating a patient's medication regimen... Policy: Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications."

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 comprehensive assessment was updated by a discharge assessment and summary for three of eight sampled patients (Patients 1, 2 and 3). This failure had the potential to cause the patients to loose services before a resolution of: shortness of breath, pain, wounds and muscle weakness. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 9, 2020, with a certification period of December 9, 2020 to February 6, 2021. Patient 1 had diagnoses that included COVID 19 (coronavirus) infection. During an interview with Patient 1's sister on April 12, 2021 at 11:22 AM, Patient 1's sister stated she did not know why the agency had discharged Patient 1. Patient 1's sister stated Patient 1 needed the agency's services, "He was just lying there. He could barely breathe." A review of Patient 1's initial assessment dated December 9, 2020 by a Registered Nurse (RN 2) indicated the following: "RN SOC [Start of Care] for covid infection. ...patient is SOB [short of breath] upon minimal exertion such as while talking. Pt's [patient's] voice is very hoarse and lungs have course crackles at bases upon auscultation [action of listening to sounds from the lungs]. Patient reports 7/10 pain [a pain scale where zero is no pain and 10 is the worst possible pain] in the esophagus [a hollow, muscular tube that connects the throat to the stomach] and reports he has been advised to see a specialist and hasn't done so yet. Pt [patient] has a wound on right big toe. Patient refused wound care at time of visit. Pt [patient] describes that it measures approximately: 0.5 x [by] 0.5 x 0.1 cm [centimeters-a unit of measurement]. PMH [prior medical history] DM [diabetes mellitus-a disease that causes high blood sugar levels] type 2 [two]... A review of Patient 1's Skilled Nursing (SN) visit notes indicated Patient 1 had received one SN visit on December 18, 2020. A review of Patient 1's physician's order dated December 19, 2020, indicated, "Discharge from Agency: ...Patient was stable and no further visits were needed. ...Patient is therefore discharged from all [name of agency] services. MD [Medical Doctor] notified." A review of Patient 1's clinical record from December 9, 2020 to December 19, 2020 was conducted. There was no documented evidence to show an OASIS (Outcome and Assessment Information Set-a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) discharge assessment had been conducted. There was no documented evidence to show a discharge summary had been completed. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:11 AM, the Admin/DPCS stated it was the Licensed Vocational Nurse Case Manager's (LVNCM 1) responsibility to schedule a Registered Nurse (RN) to conduct the OASIS discharge assessment and complete a discharge assessment for Patient 1. The Admin/DPCS stated the OASIS discharge assessment and discharge summary had not been done for Patient 1. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 7, 2020, with a certification period of December 7, 2020 to February 5, 2021. Patient 2 had diagnoses that included COVID 19 (coronavirus) infection. A review of Patient 2's initial assessment dated December 7, 2020 by the Administrator/Director of Patient Care Services (Admin/DPCS) indicated the following: "...Pt [Patient 2] is a 64 year old male... Pt has a past medical history of: HTN [hypertension-high blood pressure], high cholesterol, PNA [pneumonia]. Pt states he went onto hospital as he was experiencing SOB [shortness of breath], fever, and body aches for approx. [approximately] 3 [three] days. Pt is COVID-19 positive. ...Pt was discharged with home oxygen... Pt goal is to be free of SOB, and have no hospitalization for next 60 days." A review of Patient 2's Skilled Nursing (SN) visit notes indicated Patient 2 had received one SN visit on December 18, 2020. A review of Patient 2's physician's order dated December 19, 2020, indicated, "Final nursing visit was completed and documented on 12/18/2020 [December 18, 2020], patient was in stable condition. No further skilled nursing visits will be needed at this time. Therefore, the patient will be discharged from all [name of agency] services at this time..." A review of Patient 2's clinical record from December 7, 2020 to December 19, 2020 was conducted. There was no documented evidence to show an OASIS (Outcome and Assessment Information Set-a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) discharge assessment had been conducted. There was no documented evidence to show a discharge summary had been completed. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:15 AM, the Admin/DPCS stated she was responsible for conducting the OASIS discharge assessment and completing the discharge summary for Patient 2. The Admin/DPCS stated, "I did not do it." 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 3, 2020, with a certification period of December 3, 2020 to February 1, 2021. Patient 3 had diagnoses that included quadriplegia (paralysis of all four limbs). A review of Patient 3's initial assessment dated December 3, 2020 indicated the following: "Pt [Patient 3] reports PMH [past medical history] of quadriplegia for 2 [two] years s/p [status/post] car accident... Pt is non ambulatory, pt has very limited movement to upper extremities. Pt reports wife must move patient with manual lift. Pt and wife report they have been requesting an automatic lift due to pt size and wife having a hard time with manual lift. CM [Case Manager] was notified of need. ...Pt would benefit from PT [Physical Therapy] evaluation and treatment for strengthening and ROM [range of motion] exercises. Pt is motivated to regain some strength..." A review of Patient 3's Skilled Nursing (SN) visit notes from December 3, 2020 to December 15, 2020 was conducted. There was no documented evidence a SN visit had been made. A review of Patient 3's Physical Therapy (PT) visit notes from December 3, 2020 to December 15, 2020 was conducted. There was no documented evidence a PT visit had been made. A review of Patient 3's physician's order dated December 15, 2020, indicated, "No additional skilled nursing visits needed at this time. Patient refused all physical therapy at this time due to the member's wife testing positive for Covid-19. Therefore the patient will be discharged from all [name of agency] services at this time." A review of Patient 3's clinical record from December 3, 2020 to December 15, 2020 was conducted. There was no documented evidence to show an OASIS (Outcome and Assessment Information Set-a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) discharge assessment had been conducted. There was no documented evidence to show a discharge summary had been completed. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:17 AM, the Admin/DPCS stated it was the Licensed Vocational Nurse Case Manager's (LVNCM 1) responsibility to schedule a Registered Nurse (RN) to conduct the OASIS discharge assessment and complete a discharge assessment for Patient 3. The Admin/DPCS stated the OASIS discharge assessment and discharge summary had not been done for Patient 3. A review of the agency's policy and procedure titled, "Discharge Criteria and Process," dated December 2018, indicated the following: "Purpose: To outline the process for discharging a patient from service. Policy: When the patients' plan of care changes and this change results in discharge or reduction of services, the patient or his/her representative, as well as his/her primary physician, will be notified and involved in planning decisions. A discharge summary will be completed and filed in the clinical record. Procedure: An update to the comprehensive assessment, including required OASIS data elements, will be completed as required by regulation. For a patient requiring continuing care, assistance will be given to the patient and family/caregiver in order to manage continuing care needs after the organization's services are discontinued. Discharge instructions will be provided. A discharge summary will be completed for all discharged patients. The clinician will update the comprehensive assessment, including required OASIS data elements, as required by regulation. All discharge paperwork will be due in the office within 72 hours of the discharge date. This will include the discharge order, discharge summary, plan of care, medication profile and OASIS. Documentation will be reviewed by the Clinical Supervisor/Nursing Supervisor or designee and completed within 30 days of the discharge..."

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G 570 484.60: Care planning, coordination, quality of care was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure an individualized care plan was created and followed for five of eight sampled patients (Patients 1, 2, 4, 5 and 7) when: a. For Patient 1: the Plan of Care (POC) did not address Patient 1's shortness of breath, right toe wound care or pain. (Refer to G 572) b. For Patient 2: the Plan of Care did not address Patient 2's oxygen use, Skilled Nursing (SN) visit frequencies, medications or interventions for care. Patient 2's POC was not reviewed or signed by a physician. (Refer to G 572) c. For Patient 4: surgical staples were removed 17 days after the date indicated in the Plan of Care (POC). And Patient 4's ordered wound dressing was never ordered or supplied for Patient 4's wound care. (Refer to G 572) d. For Patient 5: the Plan of Care did not address Patient 5's oxygen use or Skilled Nursing (SN) visit frequencies. (Refer to G 572) e. For Patient 7: LVN 4 was unable to perform wound care as ordered on the plan of care due to lack of wound care supplies. (Refer to G 572) The cumulative effect of these systemic practices had the potential to cause adverse reactions to/or ineffective use of oxygen and medications; prolonged and/or failed wound healing; decline in health status due to unaddressed shortness of breath, pain and providing care that was not approved by a physician.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure an individualized care plan was created and followed for five of eight sampled patients (Patients 1, 2, 4, 5 and 7) when: 1. For Patient 1: the Plan of Care (POC) did not address Patient 1's shortness of breath, right toe wound care or pain. 2. For Patient 2: the Plan of Care did not address Patient 2's oxygen use, Skilled Nursing (SN) visit frequencies, medications or interventions for care. Patient 2's POC was not reviewed or signed by a physician. 3. For Patient 4: surgical staples were removed 17 days after the date indicated in the Plan of Care (POC). And Patient 4's ordered wound dressing was never ordered or supplied for Patient 4's wound care. 4. For Patient 5: the Plan of Care did not address Patient 5's oxygen use or Skilled Nursing (SN) visit frequencies. 5. For Patient 7: LVN 4 was unable to perform wound care as ordered on the plan of care due to lack of wound care supplies. This failure had the potential to cause adverse reactions to or ineffective use of oxygen and medications; prolonged and/or failed wound healing; decline in health status due to unaddressed shortness of breath, pain and providing care that was not approved by a physician. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 9, 2020, with a certification period of December 9, 2020 to February 6, 2021. Patient 1 had diagnoses that included COVID 19 (coronavirus) infection. A review of Patient 1's initial assessment dated December 9, 2020 by a Registered Nurse (RN 2) indicated the following: "RN SOC [Start of Care] for covid infection. ...patient is SOB [short of breath] upon minimal exertion such as while talking. Pt's [patient's] voice is very hoarse and lungs have course crackles at bases upon auscultation [action of listening to sounds from the lungs]. Patient reports 7/10 pain [a pain scale where zero is no pain and 10 is the worst possible pain] in the esophagus [a hollow, muscular tube that connects the throat to the stomach] and reports he has been advised to see a specialist and hasn't done so yet. Pt [patient] has a wound on right big toe. Patient refused wound care at time of visit. Pt [patient] describes that it measures approximately: 0.5 x [by] 0.5 x 0.1 cm [centimeters-a unit of measurement]. PMH [prior medical history] DM [diabetes mellitus-a disease that causes high blood sugar levels] type 2 [two]... A review of Patient 1's Plan of Care (POC) dated December 9, 2020 to February 6, 2021 was conducted. There was no documented evidence to show care planning for Patient 1's SOB or right big toe wound. There was no documented evidence to show the availability of pain medication. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:11 AM, the Admin/DPCS stated RN 2 was unavailable for interview. The Admin/DPCS stated it was the admitting nurse's responsibility to create the patient's plan of care based on the findings of the initial assessment. The Admin/DPCS stated RN 2 had not care planned Patient 1's SOB, right big toe wound or pain medication. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 7, 2020, with a certification period of December 7, 2020 to February 5, 2021. Patient 2 had diagnoses that included COVID 19 (coronavirus) infection. A review of Patient 2's hospital discharge order dated December 2, 2020 indicated, "Home oxygenation at 3 [three] L [liters] nasal cannula (a lightweight tube with two nasal prongs that delivers oxygen to a patient)." A review of Patient 2's Plan of Care (POC) dated December 7, 2020 to February 4, 2021 did not indicate care planning for Patient 2's oxygen use. A review of Patient 2's POC dated December 7, 2020 to February 4, 2021 was conducted. There was no documented evidence to show Skilled Nursing (SN) visit frequencies, medications or interventions for care. Patient 2's plan of care was not reviewed and signed by a physician. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:15 AM, the Admin/DPCS stated she had conducted Patient 2's admission assessment and was responsible for creating the POC. The Admin/DPCS stated the POC had not been created so it had not been sent to the physician for review and signature. The Admin/DPCS stated, "Everything seemed to have gotten missed with this patient and I don't know why." 3. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of August 4, 2020, with a certification period of August 4, 2020 to October 2, 2020. Patient 4 had diagnoses that included fracture (break) of the left femur (thighbone). During an interview with Patient 4's Primary Caregiver (PCG) on September 17, 2020, the PCG stated the home heath company did not take any responsibility to get an order to remove her father's staples. The PCG stated she had asked the nurse who came out to their home when the staples would be removed, the nurse would reply she had not heard back from the Case Manager. The PCG stated it took three weeks for the staples to be removed. The PCG stated Patient 4 came home from the hospital with a stage two wound to his sacrum (a triangular bone in the lower back) and had an order to apply Mepilex dressing. The PCG stated she contacted the agency on August 13, 2020 regarding the wound dressing. The PCG stated the nurse on the case stated she was booked the following Monday (August 17, 2020), but would bring the supplies for wound care on Tuesday (August 18, 2020). The PCG stated the home health nurse was a no show for Tuesday. A review of Patient 4's initial assessment dated August 4, 2020 indicated, "Pt [patient] was d/c [discharged] from hospital on 8/2/2020 [August 2, 2020] after inpatient stay d/t [due to] left femur fx [fracture] resulting from fall. Pts [patients] surgical site is covered with dressing." A review of Patient 4's Plan of Care (POC) dated August 4, 2020 to October 2, 2020 indicated the following physician orders: "2) SN [Skilled Nurse] to perform, demonstrate, and teach wound care. Wound care order: Location: Sacrum [a triangular bone in the lower back]/stage 2 pressure ulcer [a wound caused by prolonged pressure]. Cleanse with NS [normal saline] Pat dry Apply TAO [triple antibiotic] Apply Mepilex dressing [an absorbent, atraumatic dressing made from polyurethane foam. The outer surface of the foam is bonded to a membrane, which acts as a barrier to liquid and microorganisms. The wound contact surface of Mepilex is coated with a layer of soft silicone that does not stick to the surface of a wound or cause trauma to delicate new tissue upon removal]. 3 [three] x [times] a week/SN to perform 1 [one] x [time] a week SN to instruct patient/PCG [primary caregiver] to perform wound care instructions on non-SN days. 3) SN to remove staples Location: Left leg/Surgical incision Remove staples Apply steri strips [porous surgical tape strips which can be used to close wounds] and monitor." Patient 4's hospital discharge instructions dated July 27, 2020 and Patient 4's Initial Assessment dated August 4, 2020 did not indicate the presence of a stage 2 pressure ulcer. A review of Patient 4's Skilled Nursing (SN) visit note dated August 13, 2020 by a Licensed Vocational Nurse (LVN 1) indicated, "...patient does have a non-blanchable [pressing one's finger on the area does not force blood out of the capillaries and make the skin paler or white] sore on his right buttock cm [Case Manager-Licensed Vocational Nurse Case Manager-LVNCM 1] was called and notified, I recommend non bordered mepilex for cushion on region. CM [LVNCM 1] agreed and he said he would let MD [Medical Doctor] office know." On August 19, 2020, LVNCM 1 called in a verbal order to Patient 4's attending physician as follows: "Location: Sacrum stage 2 pressure ulcer Cleanse with NS Pat dry Apply TAO Apply Mepilex dressing 3 x a week/SN to perform 1 x a week" The August 19, 2020 wound care order was a duplicate order to the wound care order on the Plan of Care (POC) dated August 4, 2020. A review of Patient 4's Skilled Nursing (SN) visit note dated August 21, 2020 by LVN 1 indicated, "...patient does have a non-blanchable sore on his right buttock, cleaned site, applied triple abx [antibiotic] and gauze while patient is waiting on mepilex for better support, cm [LVNCM 1] has been notified. ...staples removed, used clean technique, removed all 25 staples double counted." On August 21, 2020, LVNCM 1 called in a verbal order to Patient 4's attending physician as follows: "Location: Left leg/Surgical incision Remove staples Apply steri strips and monitor." The August 21, 2020 staple removal order was a duplicate order to the staple removal order on the Plan of Care (POC) dated August 4, 2020. Staples were removed 17 days after the initial removal order dated August 4, 2020. A review of Patient 4's Skilled Nursing (SN) visit note dated August 27, 2020 by LVN 1 indicated, "...patient does have a non-blanchable sore on his right buttock, cleaned site applied triple abx and gauze while patient is waiting on mepilex for better support cm [LVNCM 1] has been notified." During an interview with LVN 1 on August 10, 2021 at 3:47 PM, LVN 1 stated she had removed Patient 4's staples. LVN 1 stated she spoke to the PCG on the phone and the PCG indicated frustration with how long it took for the agency to send someone to remove the staples. LVN 1 stated she called the office and spoke with LVNCM 1 to communicate the PCG's concerns about the lateness in removing the staples. LVN 1 stated she thought it was August 21, 2020 when she delivered a box of the Mepilex dressing to Patient 4. LVN 1 stated she did not have documentation of the delivery of the Mepilex dressing. LVN 1 stated it was LVNCM 1's responsibility to order and deliver wound care supplies to Patient 4. During an interview with LVNCM 1 on August 10, 2021 at 2:46 PM, LVNCM 1 stated he was unaware the staple removal order had been on the care plan. LVNCM 1 stated he became aware of the need to remove the staples on August 21, 2020 from LVN 1 and called in an order to the physician. LVNCM 1 stated, "I was not aware of any concerns from the family in regards to staple removal." LVNCM 1 stated he was supposed to review the patient's plan of care and coordinate the needs of the patient. LVNCM 1 stated he had not seen the wound care order on Patient 4's plan of care. LVNCM 1 stated he was given the wound care information from LVN 1 on August 19, 2020. LVNCM 1 stated he sent the order for wound care to the physician on August 19, 2020. LVNCM 1 stated the authorization request for the Mepilex did not make it to the insurance company before the PCG requested discharge. LVNCM 1 stated the Mepilex dressing was never ordered. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:25 AM, the Admin/DPCS stated LVNCM 1 was supposed to review the plan of care and make sure orders, treatments, durable medical equipment and services were ordered, scheduled and coordinated. The DPCS stated LVNCM 1 did not review the plan of care that was why Patient 4's staples were not removed timely and the Mepilex dressing was never ordered. 4. A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 5 had diagnoses that included Chronic Kidney Disease (kidney loses filtering ability). Patient 5 had a start of care on June 14, 2021, with a certification period of June 14, 2021 to August 12, 2021. A review of Patient 5's Plan of Care (POC) dated of June 14, 2021 to August 12, 2021 was conducted. There was no order for oxygen use of 4LPM (four liters per minute) via nasal cannula (tube). There was no skilled nursing visit frequency order that reflect on the conducted skilled nursing visits. A continued review of Patient Assessment Start of Care, dated June 14, 2021, indicated, "Respiratory Status: O2 (Oxygen) 4 LPM via cannula and Dyspnea (shortness of breath) during ADL's (activity of daily living)." During an interview on August 10, 2021, at 8:40 AM, with Patient 5, Patient 5 stated, "I stopped using oxygen three weeks ago. LVN 5 and I talked about it. Prior to that I was weaning myself off of it." A continued review on August 10, 2021, at 8:50 AM, with LVN 5, LVN 5 stated, "I didn't catch that the oxygen is not on the plan of care. Patient 5 stopped using it two to three weeks ago." During an interview on August 10, 2021, at 2:45 PM, with Registered Nurse (RN 1), RN 1 stated, "It was an oversight on my end about the oxygen order. It was missed on the order therefore there's no care plan." During an interview on August 12, 2021, at 11:15 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS verified there was no oxygen order in the plan of care. During a review of Physician's Order, dated July 13, 2021, the Physician's Order indicated, "Patient wound is healing properly, daughter of patient requesting to decrease visit for 2 (two) times this week and 1 (one) time next week. Patient to be discharged after final visit. MD (Medical Doctor) notified." A continued review of Patient 5's record, the electronic calendar visits were reviewed from June 2021 to August 2021. There were two skilled nursing visits on the week of July 18, 2021 to July 24, 2021. There were two skilled nursing visits on the week of July 25, 2021 to July 31, 2021. There were two skilled nursing visits on the week of August 01, 2021 to August 07, 2021. During a concurrent interview and record review, on August 10, 2021, at 4:20 PM, with Director of Patient Care Services Designee (DPCSD), DPCSD verified there's no skilled frequency visit order in the chart after the order from July 13, 2021. During a concurrent interview and record review, on August 12, 2021, at 9:40 AM, with Licensed Vocational Nurse Case Manager (LVNCM 3), LVNCM 3 stated, "There's no new updated SN frequency order in the chart after the order from July 13, 2021. The case manager is responsible for getting the SN frequency order." A continued interview on August 12, 2021, at 11:15 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS verified there was no updated SN frequency order. 5. A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 7 had diagnoses that included Cellulitis (bacterial skin infection) of left lower limb. Patient 7 had a start of care on August 03, 2021, with a certification period of August 03, 2021 to October 01, 2021. During a review of Patient 7's Plan of Care (POC) dated of August 03, 2021 to October 01, 2021 indicated, "Location #2: Left Foot lateral side/closed diabetic ulcers (wounds): Apply Betadine (solution containing iodine) and let air dry." During an observation on August 11, 2021, at 10:15 AM, Patient 7's home, Licensed Vocational Nurse (LVN 4) did not have any Betadine, unable to perform treatment as ordered on Patient 7. During an interview on August 11, 2021, at 10:40 AM, with LVN 4, LVN 4 stated, "Betadine supply was not available." During a concurrent interview and record review, on August 11, 2021, at 3:40 PM, with Licensed Vocational Nurse Case Manager (LVNCM 1) and Referral Coordinator/Data Entry (RC) both verified that the attachment that was sent out to order for wound care supplies has no Betadine on the order. A continued interview on August 11, 2021, at 3:45 PM, with LVNCM 1, LVNCM 1 stated, "Betadine could have been provided at the office and should have been ordered and it did not happen in this case." During an interview on August 11, 2021, at 4:10 PM, with Director of Patient Care Services Designee (DPCSD), DPCSD verified that LVN 4 should have notified the office that patient was out of Betadine and that the treatment was not performed as ordered. A continued interview on August 12, 2021, at 11:15 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS verified that LVN 4 was unable to perform treatment as ordered for Patient 7 due to Betadine not available. A review of the agency's policy and procedure titled, "Care Planning Process," undated, indicated the following: "Purpose: To provide clinical direction to the clinicians providing direct patient care. Policy: ...All clinicians involved in the patient's care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Definitions: Individualized Plan of Care: The patient-specific clinical plan of care includes: All patient care orders including verbal orders Measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care Medications and treatments Orders for patient-specific home health services and responsible discipline(s), treatments and procedures, including amount, frequency, and duration Patient-specific interventions and education Supplies and equipment required Frequency and duration of visits Other appropriate items such as precautions and contraindications and additional items the organization or physician may choose to include Procedure: At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient's identified needs and will review it with the patient and family/caregiver. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to: Individualized patient needs... Clinical drug monitoring, as appropriate Pain and symptom management, as appropriate Based on the assessment and conclusions, the plan of care will include, but will not be limited to: Patient specific interventions and education Identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient Specific services to be provided Actions to be taken to meet the patient goals Type, frequency, and duration of above actions Equipment and supplies All medications The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. The plan of care will be based upon the physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies, and services required to meet the patient's needs. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes. The Clinical Supervisor/Nursing Supervisor or designee will review the plan of care for all patients."

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance as follows: Based on interview and record review, the agency failed to ensure Physical Therapy (PT) needs were reassessed and additional PT visits requested, from the physician, for three of eight sampled patients (Patients 4, 5 and 6) when: 1. Patient 4 was not re-evaluated for additional Physical Therapy (PT) visits. No request for additional PT visits was made to the physician. PT discharged Patient 4 with "partial goals met." PT's reason for discharge was, "No more authorized visits." (Refer to G 966) 2. Patient 5 was not provided additional Physical Therapy visits as recommended by Physical Therapist and patient request. No request for additional PT was made to the physician. PT discharged Patient 5 with "partial goals met." (Refer to G 966) 3. Patient 6 did not receive Physical Therapy visits after resumption of care. (Refer to G 966) The cumulative effect of these systemic practices resulted in the potential to cause Patients 4, 5 and 6 to suffer a decline in physical functioning, injuries from falls and permanently impaired physical functioning.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure Physical Therapy (PT) needs were reassessed and additional PT visits requested, from the physician, for three of eight sampled patients (Patients 4, 5 and 6) when: 1. Patient 4 was not re-evaluated for additional Physical Therapy (PT) visits. No request for additional PT visits was made to the physician. PT discharged Patient 4 with "partial goals met." PT's reason for discharge was, "No more authorized visits." 2. Patient 5 was not provided additional Physical Therapy visits as recommended by Physical Therapist and patient request. No request for additional PT was made to the physician. PT discharged Patient 5 with "partial goals met." 3. Patient 6 did not receive Physical Therapy visits after resumption of care. This failure had the potential to cause Patient 4, 5 and 6 to suffer a decline in physical functioning, injuries from falls and permanently impaired physical functioning. Findings: 1. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of August 4, 2020, with a certification period of August 4, 2020 to October 2, 2020. Patient 4 had diagnoses that included fracture (break) of the left femur (thighbone). A review of Patient 4's physician's order dated August 4, 2020 indicated, "Approved for: (4) [four] ... Physical Therapy [visits]." A review of Patient 4's physical therapy evaluation dated August 6, 2020 indicated the following: "Patient seen at home for Physical Therapy evaluation. Patient is a good candidate for skilled home health Physical Therapy services 1w1 [one time a week for one week], 2w1 [two visits a week for one week], 1w1 [one time a week for one week] for therapeutic exercises, muscle re-education, balance, transfer, and gait training, establish/upgrade HEP [home exercise program], safety/fall precaution training, and patient/family training. Physical Therapists are required to manage the POC [plan of care] needed for adequate recovery and safety due to the functional impairments identified and medical complexity/comorbidities. Patient and caregiver/family will require further training to enhance better carry over and follow through of instructions given. If skilled Physical Therapy is not provided, the patient has a high probability of developing rapid regression with potential for serious complications. Patient and family are in agreement with the proposed POC." A review of Patient 4's "Physical Therapy Discharge Summary," dated August 18, 2020 indicated the following: "Reason for Discharge: ...end of auth [authorized] visits. Goals Achieved: Patient/caregiver demonstrated knowledge of health care teaching ...Partially Met Patient/caregiver demonstrated independence in ADLs [activities of daily living]/IADLs [instrumental activities of daily living] ...Partially Met Patient/caregiver demonstrated knowledge in disease process, medication, diet, safety/standard precautions ...Partially Met Patient attained an optimal level of function/independence ...Partially Met Patient demonstrated stable physiological condition ...Partially Met Patient received assistance with personal and ADL mgmt. [management] ...Partially Met" A review of a "Communication Note," dated August 21, 2020 by a Licensed Vocational Nurse Case Manager (LVNCM 1) indicated, "[Name of LVNCM 1] received a call from the [Patient 4's] daughter at 1340 [1:40 PM]. She [Patient 4's daughter] spoke to [name of LVNCM 1] about getting additional therapy for her father [Patient 4]. [Name of LVNCM 1] informed the patient's daughter that PT [Physical Therapy] notes had been faxed to the MD [Medical Doctor] for review to possibly order more." A review of a "Communication Note," dated September 4, 2020 by LVNCM 1 indicated, "[Name of LVNCM 1] received a call from the patient's [Patient 4] daughter at 1420 [2:20 PM]. Patient's daughter asked about additional PT. [Name of LVNCM 1] confirmed understanding and informed the patient's daughter that [name of agency] received PT notes but the MD did not send an order for additional physical therapy. Patient's daughter confirmed understanding and requested her father be discharged from all Home Health Services at this time. [Name of LVNCM 1] confirmed understanding. MD notified." During an interview with LVNCM 1 on August 10, 2021 at 2:46 PM, LVNCM 1 stated he had sent Patient 4's attending physician Patient 4's Physical Therapy (PT) notes. LVNCM 1 stated he had reviewed the PT notes before sending them to the physician and none of the PT notes had indicated a request for additional PT visits. LVNCM 1 stated the physician had not sent the agency an order for additional PT visits for Patient 4. LVNCM 1 stated the physician had not actually been asked for additional PT visits for Patient 4. LVNCM 1 stated he had not reported to the Administrator/Director of Patient Care Services (Admin/DPCS) about Patient 4's daughter's request for additional PT visits or that the physician had not given an order for additional PT visits. During an interview with a Physical Therapist (PT 1) on August 11, 2021 at 2:48 PM, PT 1 stated he had conducted Patient 4's initial evaluation on August 4, 2020. PT 1 stated the initial evaluation indicated his recommended visit frequency but he usually went by the authorized visits from the insurance company. PT 1 stated Patient 4 was discharged with partially met goals because he had run out of authorized visits from the insurance company. PT 1 stated Patient 4 would have benefited from additional PT visits in order to meet his goals but "I didn't have any approved visits left." PT 1 stated his usual practice was to call the agency and ask for more visits but he did not remember if he had asked for additional visits or not. PT 1 stated he was not aware of any concerns from Patient 4 or his family in regards to needing additional PT visits. PT 1 stated, "If the daughter wanted more visits then she should have called the doctor and asked for them to be approved." During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on August 12, 2021 at 10:25 AM, the Admin/DPCS stated she was unaware Patient 4 had been discharged from PT, without meeting his goals, due to non-approval of additional visits. The DPCS stated it was the agency's policy and philosophy to provide the patients services until their goals were met, wherever possible." 2. A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 5 had diagnoses that included Chronic Kidney Disease (kidney loses filtering ability). Patient 5 had a start of care on June 14, 2021, with a certification period of June 14, 2021 to August 12, 2021. During a review of Physician's Order, dated July 13, 2021, the Physician's Order indicated, "Patient has partially met goals and was advised to follow-up with MD (Medical Doctor)." A continued review of Physical Therapy Discharge Summary, dated July 13, 2021, indicated the following: "Reason for Discharge: ... Patient may benefit from further therapy at this time. Goals Achieved: Patient/caregiver demonstrated independence in ADLs [activities of daily living]/IADLs [instrumental activities of daily living] ...Partially Met Patient attained an optimal level of function/independence ...Partially Met Discharge Instructions: ... The patient may benefit from further therapy at this time to address impairments for safe return to prior level of function and to increase quality of life." During an interview on August 10, 2021, at 8:55 AM, with Patient 5, Patient 5 stated, "There's no more Physical therapy. The Therapist said he recommended 4 (four) more sessions. He said he would communicate it to the office but haven't heard anything back." During an interview on August 10, 2021, at 3:30 PM, with Physical Therapist (PT 2), PT 2 stated, "Once I do discharge assessment I check for improvement and conditions to see if there's still ongoing need for physical therapy. When I did the assessment, I did see those two things that met those two criteria. My recommendations on discharge summary I listed where she improved and where she still had impairments and that is why I recommended more therapy." During an interview on August 10, 2021, at 4:20 PM, with Director of Patient Care Services Designee (DPCSD), DPCSD stated, "Sometimes it can take a while. Case manager is responsible to initiating this recommendation." During an interview on August 10, 2021, at 4:40 PM, with Licensed Vocational Nurse Case Manager (LVNCM 3), LVNCM 3 stated, "We did not send it to MD for an order for additional PT visits." During an interview on August 12, 2021, at 10:40 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, "There was no communication in the chart that the agency communicated more PT services order to MD. PT will relay the message to agency and agency will ask MD for PT services if MD wants to continue PT." 3. A review of the Patient 6's Plan of Care (POC) with a certification period of July 17, 2021 to September 14, 2021, indicated Patient 6 had diagnoses that included Cellulitis (bacterial skin infection). Patient 6 had a start of care on July 17, 2021. During a review of Physician's Order, dated July 17, 2021, the Physician's Order indicated, "One Physical Therapy Evaluation and three Physical Therapy Follow-up Visits with Authorization period July 15, 2021 to November 12, 2021." A continued review of Patient Assessment Resumption of Care, dated July 29, 2021, indicated, "(M2200) Therapy Need: 004 - Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined)." During an interview on August 10, 2021, at 10:20 AM, with Patient 6's daughter, Patient 6's daughter stated, "We still want Physical Therapy services now that he's back from the hospital." During an interview on August 12, 2021, at 9:45 AM, with Licensed Vocational Nurse Case Manager (LVNCM 4), LVNCM 4 stated, "The nurse did not communicate any Physical Therapy orders. We would notify MD (Medical Doctor) based on RN (Registered Nurse) assessment and would get PT (Physical Therapy) order." During an interview on August 12, 2021, at 10:40 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, "It should have been re-requested or should have asked the physician to get PT services. We should have notified the physician of our findings since the nurse felt there's a need for PT. There was no communication from the nurse to the case manager to carry out the need for PT services." A review of the agency's policy and procedure titled, "Rehabilitation Care Planning," dated December 2018, indicated the following: "Procedure: After the initial assessment and as treatment progresses, the patient will be reassessed on an ongoing basis every 30 days. Patient goals will be revised based on reassessment data. Rehabilitation goals and plans will be based on, but not limited to, the following: The patient's personal goals and expectations Individualized needs for rehabilitation that are consistent with the patient's diagnosis, age, severity of disease, prognosis, and disability Rehabilitation goals and plans are designed to help the patient achieve and maintain her/her optimal level of functioning, self-care, and independence by: Managing the patient's specific health problems Maximizing the patient's emotional wellbeing in accordance with the diagnosis, prognosis, and treatment program Discharge planning is initiated early in treatment based on ongoing assessments and stated expectations for achieving treatment goals and objectives..." A review of the agency's policy and procedure titled, "Coordination of Services with other Providers," dated December 2018, indicated the following: "Purpose: To ensure the coordination of services provided by the organization and by other service providers. Policy: A Case Manager will be assigned to be responsible for coordinating services provided to the patient by the organization, including services provided directly and through contract. The Case Manager will act as liaison with other organizations or individuals also providing care to the patient to assure effective coordination of related services. Procedure: The other service provider will be responsible to contact the physician ... for orders for evaluation and treatment. The Case Manager will be responsible for the coordination between service providers, which will include, but not limited to: Organization personnel's understanding of each organization's/individual's responsibility in providing care. Initiation of communication with other organizations/individuals when there are significant changes in the patient's overall care... Issues arising from the above will be communicated to the Clinical Supervisor/Nursing Supervisor or designee... Ongoing communication regarding issues and concerns with the organizations or individuals providing care will be the responsibility of [Name of agency] management team."