Every finding on record at H.O.P.E. Professional Services, Inc.

The following reflects the findings of the California Department of Public Health during a Re-Certification Survey conducted from March 10, 2025, to March 13, 2025, The Home Health Agency unduplicated admissions during the recent 12 months : 93 patients. Current Census: 23 patients. The sample size: 17 patients. Record review with home visits: 2 patients. Record review without home visits: 13 patients. Closed record: 2 patients

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 electronically submit the completed Outcome and Assessment Information Set (OASIS - a standard set of data elements used by home health agencies to collect and report patient information, to tract and monitor quality of home health, used to develop individualized care plans, identify areas for quality improvement, and measures the effectiveness of home health services) to the Centers for Medicare and Medicaid Services (CMS) within 30 days of completing the assessment for 10 of 17 patients reviewed (Patients 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17). This failure had the potential to result in the delay of assessment, the development of patient's plan of care and the delivery of the necessary care and services needed to meet patient's individualized quality of care. Findings: On March 10, 2025, at 10 a.m., a concurrent interview and record review was conducted with the Administrator/Director of Patient Care Services (ADM/DPCS) regarding the OASIS Agency's Final Validation report from November 30, 2023, through December 12, 2024. The OASIS report had identified 10 patients in OASIS reports with submission dates more than 30 days. The ADMIN/DPCS acknowledged the 10 patients had OASIS reports with submission dates more than 30 days. The ADM/DPCS stated the Billing Coordinator (BC) was responsible for submitting the OASIS reports. On March 12, 2025, at 2:23 p.m., a concurrent interview and record review was conducted with the BC. The BC had identified the 10 patients with late submission dates of more than 30 days as follows: 1. Patient 8 was admitted to the agency on April 18, 2023, with diagnoses which included essential hypertension (high blood pressure) and peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Patient 8's last certification period was from October 15, 2023, to December 13, 2023. Patient 8 was discharged on November 30, 2023. The OASIS Discharge Assessment was completed on November 30, 2023. The BC stated the agency got locked out of IQIES (Internet Quality Improvement and Evaluation System - a web-based system used by CMS) OASIS submission since November 2023, to February 2024. The BC stated the agency was not able to submit any data due to a legal dispute between the two physicians. He stated the system got reactivated on March 26, 2024. He stated Patient 8's Discharge Assessment dated November 30, 2023, was submitted on March 26, 2024. He stated the Discharge Assessment was submitted over 30 days; 2. Patient 9 was admitted to the agency on April 7, 2023, with diagnoses which included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and hypertension (high blood pressure). Patient 9's last certification was from October 4, 2023, to December 2, 2023. Patient 9 was discharged on November 24, 2023. The Discharge Oasis Assessment was completed on November 24, 2023, and was submitted on March 26, 2024. The BC stated the agency got locked out of IQIES from November 2023 to February 2024, and he was not able to submit the data to CMS. The system got reactivated on March 26. 2024. He stated the OASIS Discharge Assessment was submitted over 30 days; 3. Patient 10 was admitted to the agency on May 24, 2023, with diagnoses which included hypertension and PVD. Patient 10's last certification was from September 21, 2023, to November 19, 2023. Patient 9 was discharged on November 19, 2023. The Oasis Discharge Assessment was completed on November 19, 2023, and was submitted on 03/26/2024. The BC stated the agency got locked out of IQIES from November 2023 to February 2024, and he was not able to submit the data to CMS. The system got reactivated on March 26, 2024. He stated the OASIS Discharge Assessment was submitted over 30 days; 4. Patient 11 was admitted to the agency on February 27, 2024, with diagnoses which included PVD. Patient 11's first certification period was from February 27, 2024, to April 26, 2024. The OASIS Start of Care Assessment was completed on February 27, 2024, and was submitted to CMS on April 18, 2024. The BC stated he was on medical leave and the OASIS Start of Care Assessment was submitted over 30 days. Patient 11 was discharged on March 1, 2024. The OASIS Discharge Assessment was completed on March 1, 2024, and was submitted to CMS on April 18, 2024. The BC stated he was on medical leave and the OASIS Discharge Assessment was submitted over 30 days; 5. Patient 12 was admitted to the agency on February 27, 2024, with diagnoses which included PVD. Patient 12's certification period was from February 27, 2024, to April 26, 2024. Patient 12 was discharged on March 31, 2024. The OASIS Discharge Assessment was completed on March 31, 2024, and was submitted to CMS on 05/28/2024. The BC stated he was on medical leave and the OASIS Discharge Assessment was submitted over 30 days; 6. Patient 13 was admitted to the agency on April 17, 2024, with diagnoses which included PVD and diabetes mellitus. Patient 13's certification period was from 04/17/2024 - 06/15/2024. The OASIS Start of Care Assessment was completed on 04/17/2024, and was submitted on 06/05/2024. The BC stated he was on medical leave and the OASIS Start of Care Assessment was submitted over 30 days; 7. Patient 14 was admitted to the agency on November 7, 2024, with diagnoses which included PVD. Patient 14's certification period was from November 7, 2024, to January 5, 2024. Patient 14 was discharged on December 5, 2024. The OASIS Discharge Assessment was completed on December 5, 2024, and was submitted to CMS on 01/10/2025. The BC stated he was on medical leave and the OASIS Discharge Assessment was submitted over 30 days; 8. Patient 15 was admitted to the agency on July 1, 2024, with diagnoses which included hypertension. Patient 5's fourth recertification was from December 28, 2024, to February 25, 2025. The OASIS Recertification Assessment dated December 27, 2024, was completed on December 27, 2024, and was submitted to CMS on February 6, 2025. The BC stated he was on medical leave and Patient 15's Recertification Assessment was submitted late over 30 days; 9. Patient 16 was admitted to the agency on April 10, 2024, with diagnoses which included epilepsy (a brain disorder that causes recurring, unprovoked convulsions). The first certification period was from April 10, 2024, to June 8, 2024. The OASIS Start of Care Assessment was completed on April 10, 2024, and was submitted on May 28, 2024. The BC stated he was on medical leave and the OASIS Start of Care Assessment was submitted over 30 days; and 10. Patient 17 was admitted to the agency on April 11, 2024, with diagnoses which included nodular prostate (the presence of firm, raised areas or lumps on the prostate gland). Patient 17 first certification period was from April 11, 2024, to June 11, 2024. The OASIS Start of Care Assessment was completed on April 11, 2024, and was submitted on July 1, 2024. The BC stated he was on medical leave and the OASIS Start of Care Assessment was submitted over 30 days. On March 12, 2025, at 3:19 p.m., the ADM/DPCS was interviewed. He stated on November 2023 through March 2024, the agency was not able to submit the OASIS data into the IQIES system of CMS. The agency later found out the two physicians who serviced the agency's patients were suing each other and the agency's name was included. He stated the owner of the agency had to hire a lawyer to clear the agency's name and on March 2024, the OASIS Assessments were submitted when the system got reactivated. He stated the Billing Coordinator was on medical leave on April 2024, and July 2024. During a review of the agency's policy and procedure titled, "...Data Entry/Transmission of OASIS Information, " dated May 23, 2019, indicated, "...The Administrator must designate two (2) employees that will possess the Agency PASSWORD and knowledge to electronically transmit OASIS data to the CMS IQIES at least monthly or within 30 days of the assessment date of the beneficiary..."

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the OASIS (Outcome and Assessment Information Set - a standardized set of data that helps measure and improve the quality of care for home health patients) Assessments were accurate and complete that included patient's past medical history, and active health status, measurables goals and outcomes, for four of 7 patients reviewed (Patients 1, 2, 4, and 6). This failure had the potential for Patients 1, 2, 4, and 6 not to receive the patient's centered plan of care necessary for the delivery of care and services appropriate for their current health status and discharge plans. 2. On March 10, 2025, Patient 2’s record was reviewed. Patient 2 was admitted to the agency with SOC date of February 2, 2025, with diagnoses which included bilateral osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and hypertension. On March 11, 2025, at 11:50 a.m., a home visit was conducted with LVN 2 for Patient 2. Patient 2 was alert to time, place, person, and situation, with periods of forgetfulness. Patient 2 was observed to be by herself in the house. Patient 2 received two phone calls from her son at the beginning of the home visit. On March 11, 2025, at 12:45 p.m., during an interview with Patient 2, she stated she lived by herself since her husband passed away seven to eight years ago. She also stated her kids would call her during the day and sometimes, her son would spend a night with her. On March 11, 2025, at 1:45 p.m., LVN 2 stated she was aware Patient 2 was living alone in the house and spoke with Patient 2’s son. She stated Patient 2’s son talked about applying for In-Home Support Service (IHHS – a program that provides in-home assistance to eligible aged, blind, and disabled individuals as an alternative to out-of-home care and enables the recipients to remain safely in their own homes), or to live with his mother. On March 12, 2025, at 11:31 a.m., during a concurrent interview and record review with the ADM/DPCS, the OASIS Start of Care Assessment dated February 2, 2025, was reviewed. The OASIS assessment indicated the following: - Sensory status was not complete; - Living Arrangement, Patient lives with other person(s) in the home, around the clock; - Digestive system was not complete; and - The Patient Medication Record did not list all of Patient 2’s medications. On March 12, 2025, at 11:31 a.m., during an interview with the ADM/DPCS, he stated he was not aware Patient 2 was living alone in the house. He stated Patient 2 stated she was living with her family, and did not inform him of the medications she was taking during the initial assessment on February 4, 2025. The ADM/DPCS stated, Patient 2 did not show him her medication bottles. 3. On March 12. 2025, Patient 4’s record was reviewed. Patient 4 was admitted to the agency with SOC date of October 9, 2024, with diagnoses which included End of Stage Renal Disease (ESRD – irreversible kidney failure). The OASIS Start of Care Assessment dated February 5, 2025, for recertification period from February 6, 2025, to April 6, 2025, indicated the following: - Immunizations was not complete; - Genitourinary was not complete; - Digestive was not complete; and - Dialysis information was not complete. 4. On March 12, 2025, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with a SOC date of November 12, 2024, with diagnoses which included peripheral vascular disease (PVD – a blood circulation disorder of the veins and arteries). The OASIS Start of Care Assessment dated November 12, 2024, for certification period from November 12, 2024, to January 10, 2025, included the following: - Psychosocial assessment was not complete; and - Gastrointestinal Assessment was not complete. On March 13, 2025, at 2:50 p.m., during an interview with the ADM/DPCS, he stated he was responsible for completion the OASIS Start of Care Assessment. He stated he should have completed all the required information from the OASIS Start of Care Assessment. The agency’s policy and procedure titled, “INITIAL ASSESSMENT,” reviewed May 23, 2019, indicated, “…During the initial and comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following…Patient’s medical and psychosocial history and present data…An evaluation of home environment…Review of medications, including prescription and over-the counter medications…Immunizations…” 1. On March 10, 2025, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 24, 2025, with diagnoses which included hypertension (high blood pressure). On March 11, 2025, at 10:30 a.m., a home visit was conducted with Licensed Vocational Nurse (LVN)1 for Patient 1. Patient 1 was alert, oriented to time, place, person, situation, and able to verbalize his needs. Patient 1 was observed with bluish discoloration of both hands. Patient 1 stated he was started on blood thinner medication on August 2024. LVN1 stated she observed Patient 1's hand discoloration on her first visit on January 21, 2025. Patient 1 was observed with pacemaker (a small device that helps regulate the heart's beat) on his left chest. Patient 1 showed a card containing the pacemaker information. The card indicated the date of pacemaker implant (July 25, 2018), the model number, serial number, the physician's contact information and the name of the hospital. LVN 1 stated she was not aware of Patient 1's pacemaker information. LVN 1 visit notes dated January 21, 2025, and January 25, 2025, did not indicate Patient 1's skin discoloration of both hands and the presence of pacemaker on his left chest. The notes did not indicate education and instructions related to the blood thinner medication and patient 1's pacemaker. During a concurrent review of Patient 1's medication profile with LVN 1, the medication profile indicated Patient 1 was taking Plavix 75 milligram (mg - a unit of measurement) one tablet by mouth daily. There was no documented evidence of Patient 1's education and instructions related to the risk for bleeding and bruising at the Start of Care (SOC) comprehensive assessment. There was no documented evidence of of the pacemaker history in Patient 1's past medical history. LVN 1 acknowledged the OASIS SOC Assessment dated January 24, 2025, did not contain the pacemaker information and skilled instruction and education of taking the blood thinner medication. On March 12, 2024, at 11:07 a.m., a concurrent interview and record review was conducted with the Administrator/Director of Patient Care Services (ADM/DPCS). The OASIS Start of Care Assessment dated January 24, 2024 indicated the following: - The pacemaker information was not entered in Patient 1's past medical and surgical history; - The most recent and additional Immunizations were not not documented; - The respiratory status was not complete; - The Assessment/Instruction/Performance section did not contain the pacemaker education, and information related to the side effects of the Plavix. During a concurrent interview and record review of Patient 1's medication profile and OASIS Start of Care Assessment on March 12, 2025, at 11:15 a.m., with the ADM/DPCS, he stated he missed the pacemaker assessment on Patient 1's left chest. The ADM/DPCS stated Patient 1's comprehensive assessment should have included patient's past surgical and medical history, education, instructions related to his pacemaker, allergy, immunization, and respiratory status. The ADM/DPCS also acknowledged Patient 1 should have received the education about the risk and side effects of the blood thinner. He stated the OASIS SOC Assessment should be complete and accurate.

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 patient's current Plan of Care (POC) and the current medication profiles were updated, accurate, and complete for two patients reviewed (Patients 1 and 2). This failure had the potential for Patient 1 and Patient 2, and their primary care givers (PCG) not to be able to identify the significant drug interactions, ineffective drug therapy and non-compliance with prescribed medications 2. On March 10, 2025, Patient 2’s record was reviewed. Patient 2 was admitted to the agency with SOC date of February 4, 2025, with diagnoses which included osteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage), embolism (obstruction or blockage in a blood vessel) and thrombosis (a condition where a blood clot forms in the vein or artery, blocking the blood flow), and hypertension (high blood pressure). Patient 2’s medication record indicated, “…Naproxen Oral 500 MG every 12 hours with food or milk by mouth…” There were no other medications listed on Patient 2’s medication record. The OASIS (Outcome and Assessment Information Set – an assessment tool) dated February 4, 2025, indicated, “…Mental Status…Memory…Forgetful…” On March 11, 2025, at 11:50 a.m., a home visit for Patient 2 was conducted with LVN 2. Patient 2 was observed awake and alert, with periods of forgetfulness. Patient 2 took a while recalling where she kept the admission packet she received from the agency. A review of the medications currently taken by Patient 1 was conducted. The undated agency document titled, “H.O.P.E PROFESSIONAL SERVICES INC. MEDICATION REVIEW,” located in Patient 2’s admission packet was left blank. On March 11, 2025, at 12:45 p.m., a medication reconciliation was conducted with LVN 2 and Patient 2. During the medication reconciliation, Patient 2 took the following medication bottles from the cabinet and placed them on the dining table. The following medications were not listed in Patient 2’s medication profile: - Atorvastatin (medication used to lower cholesterol level) 20 mg one tablet by mouth daily at bedtime; - Janumet (used to regulate blood sugar levels) 50-500 mg one tablet by mouth 2 times a day with meals; - Valsartan-hydrochlorotiazide (used to treat high blood pressure) 160-25 mg one tablet by mouth daily; - Naproxen (anti-inflammatory to relieve symptoms of arthritis such as inflammation, swelling, stiffness, and pain) 500 mg one tablet by mouth two times a day as needed for pain with meals; - Vitamin C 1,000 mg one tablet by mouth once a day; - Advil 200 mg one tablet every four to six hours as needed for pain; and - Icy Hot (menthol 16%) apply topically to affected area not more than three to four times a day as needed. During a concurrent interview with Patient 2, she stated the Vitamin C, and the Advil were not prescribed. She stated she bought them from a pharmacy. Patient two stated she was taking Vitamin C one tablet once a day and Advil two tablets two times a day for her knee pain. On March 11. 2025, at 1:03 p.m., LVN 2 was interviewed. She stated Patient 2’s medication profile should have been completed on admission. LVN 2 stated she did not check Patient 2’s medication list. LVN 2 stated Patient 2 should have a copy of her current medication profile. On March 12, 2025, at 11:31 a.m., during a concurrent interview and record review with the ADM/DPCS, the ADM/DPCS stated he conducted the admission and initial visit for Patient 2. He stated he was not aware Patient 2 was taking other medications in addition to the Naproxen. The ADM/DPCS stated Patient 2 should have a complete list of her medications. The agency’s policy and procedure titled, “Medication Profile,” reviewed on May 23, 2019, indicated, “…Upon admission to the Agency, the admitting RN (registered nurse) or therapist is provided in the admission packet a sheet on which to record the medication(s) that the patient is taking on a routine or PRN (as needed) basis…Verbal review of medications with the patient or person responsible to ensure knowledge of medication purpose, route, amount and frequency will be compared to the written label on the medication bottle…This sheet is returned to the office along with other signed documentation for admission…Nursing staff check all medications a patient may be taking…” Findings: 1. On March 10, 2025, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 24, 2025, with the diagnoses which included hypertension (high blood pressure). The current Plan of Care (POC) included a high risk medication Plavix (a blood thinner) oral 75 milligram (mg - a unit of measurement) one tablet daily by mouth. On March 11, 2025, at 10:30 a.m., a home visit was conducted with the Licensed Vocational Nurse (LVN) 1, for Patient 1. Patient 1 was observed walking with steady gait, alert and oriented to time, place, person and event. Patient 1 was able to verbalize his needs. Patient 1 was observed with skin discoloration on both hands and pacemaker on his left chest. During a concurrent medication reconciliation and interview, conducted with Patient 1 and LVN 1, the following were observed: - One medication Rosuvastatin Calcium (used to lower bad cholesterol level and fats in the blood) 40 milligram one tablet twice a day by mouth was listed in Patient 1's current POC and medication profile. The medication was not available during medication reconciliation. Patient 1 stated he ran out of medication. He stated he had not taken the medication for a month. LVN 1 stated she was not aware Patient 1 had ran out of the medication for a month. She stated she did not check if the prescription bottle was available during her visits. - Three medications were not listed in Patient 1's medication profile and current POC. The three medications were as follows: 1. Vitamin D (vitamin used to support bone, muscle and teeth) 50,000 units one capsule per week. The date prescribed was March 3, 2024; 2. Advil (used to treat fever and pain) 200 mg Liquid Gels, one tablet as needed; and 3. Pantoprazole Sodium (used for heartburn, and acid reflux) 20 mg, one tablet daily by mouth. Patient 1 stated he started taking Vitamin D when it was prescribed by his doctor on March 3, 2024. He stated he bought the Advil over-the counter two months ago and started taking the Advil two times a day as needed for pain. He stated he had been taking the Pantoprazole Sodium one tablet a day before breakfast three months ago. LVN 1 stated she was not aware of the three medications Patient 1 were currently taking. She stated she only asked Patient 1 if he took his medications. She stated she should have checked the bottles of medications on the table. On March 12, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 1's POC and medication profile was conducted with the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/DPCS stated the Licensed Nurses who conducted patient's first visit after the SOC should always perform another medication reconciliation. He stated Licensed Nurses should always check all prescription medications and over-the counter medications on every visit.

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 facility failed to ensure the approved visit frequencies in the patient’s Plan of Care (POC) were followed when the agency did not notify the physician of missed visits for three of 7 patients reviewed (Patients 4, 6 and 7). This failure had the potential for the Patients 4, 6 and 7, not to receive the care and services from the skilled nurse (SN) as indicated in the POC. Findings: 1. On March 12, 2025, Patient 4’s record was reviewed. Patient 4 was admitted to the agency with a SOC date of October 9, 2024, with diagnoses which included End Stage Renal Disease (ESRD – irreversible kidney failure). The POC for the certification period from February 6, 2025, to April 6, 2025, was reviewed. The POC indicated an order for skilled nurse (SN) visit for “…1W9 (one visit a week for nine weeks)…” The calendar of visits for the week of February 26, 2025, to February 29, 2025, was reviewed. The calendar indicated there was no SN visit during the week of February 23, 2025, to March 1, 2025. There was no documented evidence a communication note was made to inform the physician of the missed visit on the week of February 23, 2025, to March 1, 2025. 2. On March 12, 2025, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with a Start of Care (SOC) date of November 12, 2024, with diagnoses which included peripheral vascular disease (PVD – a blood circulation disorder of the veins and arteries). The POC for the certification period from November 11, 2024, to January 10, 2025, was reviewed. The POC indicated an order for SN visit for “…Daily x3 (three days); 1W8 (one visit a week for eight weeks)…” The agency’s document titled, “POST ARTERIAL FOLLOW UP,” dated November 27, 2024, indicated, “…PLEASE SEE PATIENT FOR THE NEXT 3 (three) CONSECUTIVE DAYS: 11/27/24 – 11/29/24…” The calendar of visits for the week of November 24 – 30, 2024 was reviewed. The calendar indicated there was no SN visit on November 27, 2024, and November 29. 2024, as indicated on the post arterial follow up orders dated November 27, 2025. There was no documented evidence a communication note was made to inform the physician of missed visits on November 27, 2024, and November 29, 2024. 3. On March 13, 2025, Patient 7’s record was reviewed. Patient 7 was admitted to the agency with a SOC date of October 31, 2024, with diagnoses which included diabetes mellitus (a disorder characterized by difficulty in blood sugar control) and hypertension (high blood pressure). The POC for the certification period from October 31, 2024, to December 29, 2024, was reviewed. The POC indicated an order for SN visit for “…1W9 (one visit a week for nine weeks)…” The agency’s document titled, “POST ARTERIAL FOLLOW UP,” dated December 3, 2024, indicated, “…PLEASE SEE PATIENT FOR THE NEXT 3 CONSECUTIVE DAYS:12/03/24 – 12/05/24…” The calendar of visits for the week of November 24, 2024, to November 30, 2024, and for the week of December 1, 2024, to December 7, 2024, were reviewed. The calendar of visits indicated there were no SN visit during the week of November 24, 2024, to November 30, 2024, and there was no visit conducted on December 3, 2024, as indicated on the post arterial follow-up orders dated December 3, 2024. There was no documented evidence of missed visit notes, and the physician was not notified of the missed visits on the week of November 24, 2024, to November 30, 2024, and on December 3, 2024. On March 11, 2025, at 1:45 p.m., during an interview with Licensed Vocational Nurse (LVN) 2, she stated if the staff had a missed visit, the agency and the physician should be notified. On March 13, 2025, at 2:50 p.m., during an interview with the Administrator/Director of Patient Care Services (ADM/DPCS), he stated the procedure for missed visit was to notify the patient’s physician for the missed visit. He also stated there should also be a documentation for the reason of the missed visit. The agency’s policy and procedure titled, “Staffing Issues,” reviewed May 23, 2019, indicated, “…Whenever agency staff is unable to complete a visit…at the scheduled time…the staff member will notify the case manager and document the occurrence…If the visit cannot be rescheduled during the same…week a missed visit note will be sent to the physician explaining the occurrence…”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the physician's post operative orders related to embolization (a procedure that involves blocking a blood vessel with small particles or materials to control bleeding) and angioplasty (a procedure used to open narrowed or blocked arteries) were not entered and documented in patient's current Plan Of Care (POC) for five of seven patients reviewed (Patient 3, 5, 2, 6, and 7). This failure had the potential for Patients 3, 5, 2, 6, and 7, not to receive the necessary treatment, care, education and instructions related to the procedures they received. 3. On March 10, 2025, Patient 2’s record was reviewed. Patient 2 was admitted to the agency with SOC date of February 4, 2025, with diagnoses which included osteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage), embolism (obstruction or blockage in a blood vessel) and thrombosis (a condition where a blood clot forms in the vein or artery, blocking the blood flow). The Face-to-Face Encounter dated February 4, 2025, indicated Patient 2 had a right genicular embolization on the right leg with the left groin access. The “Post Arterial Follow-Up,” dated February 4, 2025, indicated, “…Home health nurse to visit the patient on the day of surgery (within 2-3 hours of the patient been home) for the following…Reapply pressure dressing…To check for hematoma…Check for any bleeding, flank discoloration, flank pain…Changes in texture and firmness…Nurse to check pulse on both legs by palpation and by Doppler…If there is bleeding/hematoma or change in color of foot, let physician’s office know right away and/or call 911…Nurse to advice patient of the following…No bending from the waist…No activity for 24 hours…Ice on the groin for 24 hours…Warm blanket on the foot up to the knee on the leg the patient was operated on…Nurse to review discharge summary with patient and re-explain to patient and family…On second day, nurse to assist with ambulation without stressing the area of the groin (i.e. no bending of the waist)…Home Health Nurse to visit patient within 24 hours to remove pressure dressing (if there is no adverse outcome) and apply a light dressing (if needed)…Nurse must see patient for 3 days consecutively including day of arterial followed by once a week as needed…” The Face-to-Face Encounter dated February 18, 2025, indicated Patient 2 had a genicular embolization on the left leg with the right groin entry. The “Post Arterial Follow-Up,” dated February 18, 2025, indicated, “…Home health nurse to visit the patient on the day of surgery (within 2-3 hours of the patient been home) for the following…Reapply pressure dressing…Check for hematoma…Check for any bleeding, flan (sic) discoloration, flan (sic) pain…Changes in texture and firmness…Nurse to check pulse on both legs by palpation and by Doppler…If there is bleeding/hematoma or change in color of foot, let physician’s office know right away and/or call 911…Nurse to advice patient of the following…No bending from the waist…No activity for 24 hours…Ice on the groin for 24 hours…Warm blanket on the foot up to the knee on the leg the patient was operated on…Nurse to review discharge summary with patient and re-explain to patient and family…On second day, nurse to assist with ambulation without stressing the area of the groin (i.e. no bending of the waist)…Home Health Nurse to visit patient within 24 hours to remove pressure dressing (if there is no adverse outcome) and apply a light dressing (if needed)…Nurse must see patient for 2 days consecutively including day of arterial followed by once a week as needed…” The Plan of Care for Certification Period of February 4, 2025, to April 4, 2025, did not include the Post Arterial Follow-Up orders. 4. On March 12, 2025, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with a Start of Care (SOC) date of November 12, 2024, with diagnoses which included peripheral vascular disease. The Face-to-Face Encounter dated November 12, 2024, indicated Patient 6 had an angiogram (a medical imaging procedure that uses X-rays to visualize blood vessels and blood flow) on the left leg with the right groin access. The “POST ARTERIAL FOLLOW UP,” dated November 12, 2024, indicated, “…Home health nurse to visit the patient on the day of surgery (within 2-3 hours of the patient been home) for the following…reapply pressure dressing…to check for hematoma…Check for any bleeding, flan (sic) discoloration, flan (sic) pain…Changes in texture and firmness…Nurse to check pulse on both legs by palpation and by Doppler…If there is bleeding/hematoma or change in color of foot, let physician’s office know right away and/or call 911…Nurse to advice patient of the following…No bending from the waist…No activity for 24 hours…Ice on the groin for 24 hours…Warm blanket on the foot up to the knee on the leg the patient was operated on…Nurse to review discharge summary with patient and re-explain to patient and family…On second day, nurse to assist with ambulation without stressing the area of the groin (i.e. no bending of the waist)…Home Health Nurse to visit patient within 24 hours to remove pressure dressing (if there is no adverse outcome) and apply a light dressing (if needed)…Nurse must see patient for 3 days consecutively including day of arterial followed by once a week as needed…” The Face-to-Face Encounter dated November 27, 2024, indicated Patient 6 had an angiogram on the left groin. The ”POST ARTERIAL FOLLOW-UP,” dated November 27, 2024, indicated the same orders from the first episode. The Plan of Care for Certification Period of November 12, 2024, to January 10, 2025, did not include the Post Arterial Follow-Up orders. 5. On March 13, 2025, Patient 7’s record was reviewed. Patient 7 was admitted to the agency with a SOC of October 31, 2024, with diagnoses which included PVD. The Face-to-Face Encounter dated December 3, 2024, indicated Patient 7 had an angioplasty of the right leg, with the left groin entry. The “Post Arterial Follow-Up,” dated December 3, 2024, indicated, “…Home health nurse to visit the patient on the day of surgery (within 2-3 hours of the patient been home) for the following…reapply pressure dressing…to check for hematoma…Check for any bleeding, flan (sic) discoloration, flan (sic) pain…Changes in texture and firmness…Nurse to check pulse on both legs by palpation and by Doppler…If there is bleeding/hematoma or change in color of foot, let physician’s office know right away and/or call 911…Nurse to advice patient of the following…No bending from the waist…No activity for 24 hours…Ice on the groin for 24 hours…Warm blanket on the foot up to the knee on the leg the patient was operated on…Nurse to review discharge summary with patient and re-explain to patient and family…On second day, nurse to assist with ambulation without stressing the area of the groin (i.e. no bending of the waist)…Home Health Nurse to visit patient within 24 hours to remove pressure dressing (if there is no adverse outcome) and apply a light dressing (if needed)…Nurse must see patient for 3 days consecutively including day of arterial followed by once a week as needed…” The Face-to-Face Encounter dated December 11, 2024, indicated Patient 7 had a angioplasty of the left leg with right groin entry. The ”POST ARTERIAL FOLLOW-UP,” dated December 11, 2024, indicated the same orders. The Plan of Care for Certification Period of October 31, 2024, to December 29, 2024, did not include the Post Arterial Follow-Up orders. On March 13, 2025, at 2:50 p.m., during an interview with the ADM/DPCS, he stated He stated the physician orders post angiogram should have been included in the patient’s POC. The agency’s policy and procedure titled, “CARE PLANNING PROCESS,” reviewed May 23, 2019, indicated, “…PURPOSE…To provide clinical direction to clinicians providing direct patient care…A written plan of care will be initiated within five (5) days of the start of care and updated at least every 60 days or as patient’s condition warrants…The clinical plan of care includes…interventions appropriate to each discipline…functional limitations, precautions, activities…treatments, safety measures, instructions…The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders… Findings: 1. On March 10, 2025, Patient 3's record was reviewed. Patient 3 was admitted to the agency with the Start of Care (SOC) date of February 14, 2025, with diagnoses which included peripheral vascular disease (PVD - a circulatory condition in which narrowed vessels reduce blood flow to the limbs). Patient 3's Face to Face Encounter (a certifying physician meet the patient that requires home health services) dated February 14, 2025, indicated Patient 3 had a left leg angioplasty (a procedure that widens blocked or narrowed arteries or veins) with right groin entry. The "POST ARTERIAL FOLLOW UP" orders dated February 14, 2025 to February 16, 2025, indicated the following: - "Home Health Nurse to visit patient the day of (within 23 hours of patient been home); - Re-apply pressure dressing; - Check for hematoma; - Check for any bleeding, flan discoloration, flan pain; - Changes in texture and firmness; - Nurse to check pulse on both legs by palpation and by Doppler; - If there is any evidence of bleeding/hematoma or change in color of foot, let physician's office know right away and/or call 911; - Nurse to advice patient of no bending from waist, no activity for 24 hours, ice on groin for 24 hours, and warm blanket on the foot up to the knee on the leg the patient was operated on; - Nurse to review discharge summary with patient and re-explain to patient and family; - On second day, nurse to assist with ambulation without stressing the area of the groin (i.e. no bending of the waist); - Home Health Nurse to visit patient within 24 hours to remove pressure dressing(if there is no adverse outcome) and apply a light dressing (if needed); - Nurse to see patient for 3 days consecutively including the day of arterial followed by once a week as needed." Patient 3's Face to Face Encounter with the physician dated February 26, 2025, indicated Patient 3 had an angioplasty of the right leg, with left groin entry. Patient 3 was discharged from the clinic at 6 p.m. The physician's orders indicated the same "POST ARTERIAL FOLLOW UP" for the second procedure. The order indicated for "...Nurse must see patient for 2 days consecutively starting 02/27/25 - 02/28/25..." Patient 3's Face to Face Encounter with the physician dated March 11, 2025, indicated Patient 3 had "genicular embolization (a procedure that reduces knee pain caused by osteoarthritis) right knee with left groin entry..." The physician's orders indicated the same "POST ARTERIAL FOLLOW UP" for the third procedure. The order indicated for "...Nurse must see patient for 2 days consecutively including the day of arterial followed by once a week as needed..." The physician's orders for the three procedures were not documented in Patient 3's Plan of Care (POC) during the certification period from February 14, 2025 to April 14, 2025. The POC did not contain Patient 3's allergy. 2. On March 12, 2025, Patient 5's record was reviewed. Patient 5 was admitted to the agency with the SOC date of February 18, 2025, with diagnoses which included embolism and thrombosis of other arteries. Patient 5's Face to Face Encounter with the physician dated February 18, 2025, indicated Patient 5 had a right genicular embolization (a minimally invasive procedure used to treat chronic knee pain caused by osteoarthritis - a type of arthritis that occurs when flexible tissue at the ends of bones wear down) of the right knee with left groin entry. The "POST ARTERIAL FOLLOW UP" orders indicated, "Home Health Nurse to visit patient the day of within 23 hours of patient been home for the following...Re-apply pressure dressing...Nurse to check pulse on both legs by palpation and by Doppler...Nurse to advise patient...No bending from the waist...Nurse to review discharge summary with patient...family...Nurse to assist with ambulation...Nurse must see patient for 2 days consecutively...followed by once a week as needed..." The Post Arterial Follow Up orders were not entered and documented in Patient 5's POC during the certification period from February 18, 2025 to March 18, 2025. The POC did not contain Patient 5's allergy. On March 12, 2025, at 12:35 p.m., a concurrent interview and record review was conducted with the Administrator (ADM)/Director of Patient Care Services (DPCS). The ADM/DPCS acknowledged the Post Arterial Follow Up orders were not documented in Patients 3, and 5's current POC. The ADMIN/DPCS stated the orders should have been carried out to the POC at the start of care. He stated the POC should have included the patient's allergy.

The following reflects the findings of the California Department of Public Health during a Re-Certification Survey conducted from February 28 to March 3, 2022. Representing the California Department of Public Health: Surveyor 29623, HFEN; and Surveyor 32191, HFEN. The Home Health Agency unduplicated admissions during the recent 12 months: 229 patients. Current census: 63 patients. The sample size: 7 patients. Record review with home visits: 2 patients. Record review without home visits: 3 patients. Closed record review: 2 patients.

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 medications listed in patient's Plan of Care (POC) and current medication home profile were updated, accurate, and complete for two of seven sampled patients reviewed (Patient 1 and 4) when: 1. For Patient 1, - a. Three medications were discontinued and were still listed in the current home medication profile and the POC; - b. Three medications Patient 1 was currently taking at home were not listed in the agency's POC and current home medication profile; and 2. For Patient 4, - One medication was listed on Patient 4's current medication profile and POC, but Patient 4 had stopped taking the medication. These failures had the potential for Patient 1, Patient 4, and their primary care givers (PCG) not to be able to identify the significant side effects of the medications, significant drug interactions, ineffective drug therapy and noncompliance with prescribed drug therapies. Findings: 1. On February 28, 2022, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 31, 2022, with diagnoses which included peripheral vascular disease (PVD - a blood circulation disorder of the arteries and veins) and open wound left lower leg. On March 1, 2022, at 11:26 p.m., a home visit was conducted for Patient 1 with Licensed Vocational Nurse (LVN) 1. Patient 1 was observed sitting in a sofa chair, alert and able to verbalized her needs. Patient 1 was able to sign the consent for the home visit in the presence of her PCG. Patient was observed with tegaderm dressing (a type of wound dressing) on the middle front area of her left leg. Patient 1 was observed with multiple discoloration of both legs and minimal swelling of the left ankle. On March 1, 2022, at 12:25 p.m., a concurrent interview and medication review was conducted with Patient 1's PCG and LVN 1. During the medication review the following were observed: - Three medications that were listed in the current POC and Patient 1's current home medication profile had been discontinued prior to the home visit. Patient 1's PCG was interviewed. The PCG stated the Atorvastatin was discontinued by the physician on October 22, 2021, the Tylenol 300/30 mg was discontinued on February 28, 2022, and the Aspirin 81 mg Patient 1 had stopped using six months ago. The PCG stated Patient 1 did not like taking the Aspirin because she developed bruising on her arms. LVN 1 stated she did not know the bottle of Atorvastatin 10 mg was not available, but the container of Lovastatin 10 mg was available when she checked Patient 1's medication. LVN 1 stated the Tylenol 300/30 mg was recently discontinued and she was not able to update Patient 1's medication profile and the agency's medication list. LVN 1 stated the Aspirin 81 mg tablet was still available, but she was not aware Patient 1 had stopped taking the Aspirin six months ago until the PCG had mentioned today during the home visit. - The medication containers of Lovastatin 10 mg tablet, Tramadol 50 mg tablet and Tetracycline 500 mg capsule were observed. The medications were not listed in the agency's current POC and Patient 1's current medication home profile. Patient 1's PCG was interviewed. The PCG stated Patient 1 had been taking the Lovastatin since January 25, 2022, the Tramadol 50 mg was prescribed on February 16, 2022, and the Tetracycline 500 mg capsule was prescribed recently for Patient 1's wound on February 24, 2022. LVN 1 stated she was checking the Atorvastatin medication in Patient 1's medication profile but not the Lovastatin medication that Patient 1 had been taking at home. LVN 1 stated she was not aware Patient 1 had not been taking the Tramadol medication at night. LVN 1 stated she was aware of Patient 1's antibiotic Tetracycline but was not able to update Patient 1's medication profile and agency's medication list. On March 2, 2022, at 11:57 a.m., the Administrator/Director of Patient Care Services (DPCS) was interviewed. The Administrator/DPCS stated LVN 1 should have conducted medication reconciliation on every visit for Patient 1 and should have updated Patient 1's medication profile at home and the agency's medication list immediately. 2. On February 28, 2022, Patient 4's record was reviewed. Patient 4 was admitted to the agency with the Start of Care (SOC) date of January 27, 2022, with diagnoses which included peripheral vascular disease (PVD-- blood circulation disorder arteries or veins ). On March 1, 2022, at 10:30 a.m., a home visit was conducted for Patient 4 with Licensed Vocational Nurse (LVN) 2. Patient 4 was observed alert, oriented, ambulatory and able to verbalizes her needs. On March 1, 2022, at 10:45 a.m., a concurrent interview and medication review was conducted with Patient 4 and LVN 2. During the medication review the following were observed: - One medication that was listed in the current POC and Patient 1's medication profile was discontinued prior to the home visit. Patient 4's was interviewed. The Patient 4's stated the Calcium (supplement) 600 milligram (mg) Vitamin D 3 10 microgram (mcg) was finished and run out. Patient 4's stated on January 2022, she had a follow up Doctor's appointment Calcium was discontinued by the physician. Patient 4's was unable to recall when is the last date she stopped taking the Calcium supplement. The LVN 2 confirmed the Calcium (supplement) 600 milligram (mg) Vitamin D 3 10 microgram (mcg) of Patient 4 was discontinued. On March 1, 2022, at 9:42 a.m., an interview and record review was conducted with the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/DPCS stated probably the Registered Nurse (RN) and the Data Entry (DE) transcribed the medications incorrectly in the POC due to Patient 4 was a previous patient. The DPCS acknowledged the medications listed in patient 4 Plan of Care (POC) and current medication medication profile were inaccurate. The DPCS confirmed Patient 4 Calcium (supplement) 600 milligram (mg) Vitamin D 3 10 microgram (mcg) was been discontinued. The review of the agency policy and procedure titled, "Medication Profile" dated July 8, 2008 was reviewed. The policy indicated, "...Patients/clients receiving medications administered by the agency will have a current, accurate medication profile in the clinical record..."

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 the approved visit frequencies in the patient's Plan Of Care (POC) were followed when the agency failed to notify the attending physician of missed visits for three of seven sampled patients reviewed (Patients 1, 3 and 4). This failure had the potential for the patients not to receive the care and services from the skilled nurse (SN) as indicated in the POC. 3. On March 1, 2022, the record of Patient 4 was reviewed. Patient 4 was admitted to the agency on January 27, 2022, with a primary diagnosis of peripheral vascular disease (PVD- blood circulation disorder arteries or veins). The certification period reviewed was January 27, 2020, through March 27, 2022). Patient 4's record included a physician's order dated February 8, 2022, for "...SN (skilled nursing) frequency visit: QD x 2 days, 1 W 8..." There was one SN visit missed the week of February 8, 2022, through February 12, 2022. There was no documented evidence the physician was notified of the missed SN visit. On March 2, 2022, at 2:15 p.m., Patient 4's record were reviewed with the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/DPCS acknowledged one SN visit was missed and the physician was not notified of the missed SN visit on the week of February 8, 2022, through February 12, 2022. The ADM/DPCS stated the SN visit should have been done as ordered by the physician for Client 4. The review of the agency's policy and procedure titled, "MISSED VISITS" dated July 14, 2008 was reviewed. The policy indicated, "...The Case Managers must complete the Missed Visit Report Form explaining why the visits were missed and what actions were done to meet the patient's needs...The MD will be notified and a copy of report will be faxed to the MD office..." Findings: 1. On February 28, 2022, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 31, 2022, with diagnoses which included peripheral vascular disease (PVD - a blood circulation disorder of the veins and arteries) and open wound left lower leg. The plan of care (POC) for the certification period from January 31, 2022 to March 31, 2022, was reviewed. The POC indicated an order for skilled nurse (SN) visit for "2 W 1 ( two visits for week 1) ; 1 W 7 (one visit a week for seven weeks). On March 2, 2022, the SN visit notes and Patient 1's calendar of visits from January 31, 2022 to February 5, 2022, was reviewed. The calendar indicated there was a communication note on February 3, 2022. There was no documented evidence of nursing visit note on February 3, 2022. The agency's form titled, "Communication Note," dated February 3, 2022 was reviewed. The note indicated, "...Missed visit due to patient not home and not available. Called patient and grandson stated patient was at her PCP (Primary Care Physician)..." There was no documented evidence the agency submitted the missed visit communication note to Patient 1's attending physician. On March 2, 2022, at 10:29 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Patient 1 had a medical appointment on February 3, 2022. LVN 1 stated she created the communication note and forwarded the note to the agency. LVN 1 stated she did not notify Patient 1's attending physician. On March 2, 2022, at 10:45 a.m., the Administrator/Director of Patient Care Services (ADM/DPCS) was interviewed. The ADM/DPCS stated the SN could have called the attending physician for the missed visit and the agency's staff should have notified Patient 1's attending physician the same day. The ADM/DPCs acknowledged the physician was not notified and the communication note for missed visit was not faxed to Patient 1's attending physician. 2. On March 3, 2022, Patient 3's record was reviewed. Patient 3 was admitted to the agency with the SOC date of January 10, 2022, with diagnoses which included atherosclerosis of arteries (a disease where there is build up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) both lower extremities. The POC for the certification period from January 10, 2022 to March 3, 2022, was reviewed. The POC indicated an order for skilled nurse visit for "2 W 1 (Two visits in week 1), 1 W 8 (one visit a week for eight weeks). The calendar of visits for the week of January 10, 2022 to March 5, 2022, was reviewed. The calendar indicated there was no SN visit during the week of February 6, 2022 to February 12, 2022. The agency's form titled, "Communication Note," dated February 9, 2022, was reviewed. The note indicated, "...Patient not answering her phone called her several times..." On March 3, 2022, at 10:31 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she called Patient 3 multiple times on February 3, 2022. LVN 1 stated Patient 3 did not return her call until the following week. LVN 1 stated she generated the missed visit communication note and sent the note to the agency. LVN 1 stated she did not notify Patient 3's attending physician. On March 3, 2022, at 10:48 a.m., the Administrator/Director of Patient Care Services (ADM/DPCS) was interviewed. The ADM/DPCS stated the agency's staff should have notified Patient 3's attending physician of missed visit and should have faxed the communication note to the physician's office.

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 observation, interview, and record review, the agency failed to ensure the following were included in the patient's individualized Plan of Care (POC): - Wound care treatment frequency, medications and supplies; - Patient and Primary Caregiver (PCG) education regarding dressing changes using aseptic technique (free from contamination); and - Specific measurable goals and outcomes for the wound for one of seven patients reviewed (Patient 1). This failure increased the potential for Patient 1 and Patient 1's PCG to not to be educated regarding wound care treatment, specific goals towards the improvement of Patient 1's wound and how to avoid the development of infection during dressing changes. Findings: On February 28, 2022, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 31, 2022, with diagnoses which included peripheral vascular disease (PVD - a blood circulation disorder of the arteries and veins) and open wound on the left lower leg. The initial assessment dated January 31, 2022, indicated Patient 1 had a wound on the left leg. The POC for the certification period from January 31, 2022, to March 31, 2022, was reviewed. The POC indicated Patient 1 had orders for Silver Sulfadiazine (used to treat wound infection) 1% (percent) topical cream apply to affected area daily. The POC did not indicate the wound care treatment management frequency, supplies, and patient/PCG's instructions regarding wound care. On March 1, 2022, at 11:25 a.m., a home visit for Patient 1 was conducted with Licensed Vocational Nurse (LVN) 1. Patient 1 was observed awake, alert, and able to verbalize her needs. Patient 1's PCG was present during the home visit. Patient 1 was observed with a tegaderm (a type of wound dressing) on the middle area of her left leg. Patient 1 was observed with scattered multiple discoloration of both lower legs and minimal swelling of her left ankle. On March 1, 2022, at 11:40 a.m., LVN 1 was observed performing wound care treatment as follows: - Removed the old dressing; - Cleaned the wound area using the derma wound cleanser liquid solution in a spray container and sterile gauze; - Pat and dry the wound area; - Applied skin protection Ointment with Vitamin D over the wound area; - Covered the wound with sterile 4x4 gauze; - Wrapped the leg with kerlix bandage (used to provide absorbency, to secure the primary dressing); and - Wrapped the leg using ACE wrap bandage (a stretchable cloth bandage). On March 1, 2022, at 11:52 a.m., Patient 1 was observed with Elastoplast (adhesive dressing) dressing around her lower abdomen area. LVN 1 was observed performing the following: - Removed the Elastoplast adhesive dressing using the derma wound cleanser liquid spray solution; - Removed the dressing on Patient 1's left groin; - Cleaned the left groin surgical site with dermal wound cleanser spray solution using sterile 4x4 gauze; - Pat and dry the surgical site; - Applied skin protection Ointment with Vitamin A & D; and - Applied sterile tegaderm dressing on the left groin. LVN 1 instructed Patient 1's PCG to remove the left groin dressing on Thursday (March 3, 2022) and keep the area dry. A concurrent interview was conducted with LVN 1. LVN 1 stated Patient 1 had right leg angioplasty (a surgical procedure used to widen narrowed or obstructed arteries or veins) using the left groin approach on February 28, 2022, and left leg angioplasty on February 11, 2022, using the right groin approach. On March 1, 2022, at 12:30 p.m., a concurrent interview and POC review was conducted with LVN 1. LVN 1 stated she will visit Patient 1 for two consecutive days on March 2, and 3, 2022, to change the left groin dressing, check for any hematoma (bad bruise caused by collection of blood under the skin) or bleeding from the site of the angioplasty. LVN 1 was not able to find the wound care treatment orders she performed during the home visit in Patient 1's POC. There were no instructions or education to Patient 1 and Patient 1's PCG on wound care and care after angioplasty. LVN 1 stated the surgical clinic had post op (after surgery) instructions for Patient 1, but they were not written in the POC. LVN 1 stated the agency should have received the physician's orders for Patient 1 after the procedure. LVN 1 acknowledged all wound care treatment and care after angioplasty should have been included in the POC. On March 2, 2022, Patient 1's record was reviewed. The physician's orders titled, "Post Arterial Follow Up," was reviewed. The physician's orders indicated, "...Home health nurse to visit patient the day of (with-in 2-3 hours of patient been home)...Re-apply dressing pressure, to check for hematoma, check for bleeding, flank discoloration, flank (side of the body between the ribs and the hip) pain...Nurse to advise patient...No bending from the waist, no activity for 24 hours...Home health nurse to visit patient within 24 hours to remove pressure dressing...apply tegaderm dressing...may remove tegaderm dressing after 72 hours...Please see patient for the next 3 consecutive days..." On March 2, 2022, at 11:35 a.m., a concurrent interview and record review for Patient 1 was conducted with the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/DPCS was not able to find documented evidence in Patient 1's record or in the POC of physician's orders for wound care and post angioplasty care. The ADM/DPCS stated the wound care treatment and post angioplasty care should have been included in Patient 1's current POC. The agency's undated policy and procedure titled, "Physician Orders/Plan of Care," was reviewed. The policy indicated, "...The Plan of Care will include...Medications and treatment...Activities permitted...Safety measures...Proposed frequency of services...Instructions to patient and family...Statement of treatment goals..."

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure patient's individualized Plan of Care (POC) was revised to reflect current clinical condition, skilled nursing care and medical management for one of seven patients reviewed (Patient 1). This failure increased the potential for Patient 1 not to receive the necessary care and services for wound care and post operative care after angioplasty (a surgical procedure used to open blocked arteries). Findings: On February 28, 2022, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 31, 2022, with diagnoses which included peripheral vascular disease (PVD - a blood circulation disorder of the arteries and veins) and open wound on the left lower leg. The initial assessment dated January 31, 2022, indicated Patient 1 with wound on the left leg. The POC for the certification period from January 31, 2022, to March 31, 2022, was reviewed. The POC indicated under section of goals "...Wound will heal without complication..." The POC did not indicate wound care treatment management frequency, supplies, and patient/PCG's instructions regarding wound care. On March 1, 2022, at 11:25 a.m., a home visit for Patient 1 was conducted with Licensed Vocational Nurse (LVN) 1. Patient 1 was observed awake, alert, and able to verbalize her needs. Patient 1's PCG was present during the home visit. Patient 1 was observed with a tegaderm (a type of wound dressing) on the middle area of her left leg. Patient 1 was observed with scattered multiple discoloration of both lower legs and minimal swelling of her left ankle. On March 1, 2022, at 11:40 a.m., LVN 1 was observed performing wound care treatment as follows: - Removed the old dressing; - Cleaned the wound area using the derma wound cleanser liquid solution in a spray container and sterile gauze; - Pat and dry the wound area; - Applied skin protection Ointment with Vitamin D over the wound area; - Covered the wound with sterile 4x4 gauze; - Wrapped the leg with kerlix bandage (used to provide absorbency, to secure the primary dressing); and - Wrapped the leg using ACE wrap bandage (a stretchable cloth bandage). On March 1, 2022, at 11:52 a.m., Patient 1 was observed with Elastoplast (adhesive dressing) dressing around her lower abdomen area. LVN 1 was observed performing the following: - Removed the Elastoplast adhesive dressing using the derma wound cleanser liquid spray solution; - Removed the dressing on Patient 1's left groin; - Cleaned the left groin surgical site with dermal wound cleanser spray solution using sterile 4x4 gauze; - Pat and dry the surgical site; - Applied skin protection Ointment with Vitamin A & D; and - Applied sterile tegaderm dressing on the left groin. LVN 1 instructed Patient 1's PCG to remove the left groin dressing on Thursday (March 3, 2022) and keep the area dry. A concurrent interview was conducted with LVN 1. LVN 1 stated Patient 1 had right leg angioplasty (a surgical procedure used to widen narrowed or obstructed arteries or veins) using the left groin approach on February 28, 2022, and left leg angioplasty on February 11, 2022, using the right groin approach. On March 1, 2022, at 12:30 p.m., a concurrent interview and POC review was conducted with LVN 1. LVN 1 stated she will visit Patient 1 for two consecutive days on March 2, and 3, 2022, to change the left groin dressing, check for any hematoma (bad bruise caused by collection of blood under the skin) or bleeding from the site of the angioplasty. LVN 1 was not able to find the wound care treatment she performed during the home visit in Patient 1's POC. There was no instructions or education to Patient 1 and Patient 1's PCG on wound care and care after angioplasty. LVN 1 stated the surgical clinic had post op (after surgery) instructions for Patient 1, but was not written in the POC. LVN 1 stated the agency should have received the physician's orders for Patient 1 after the procedure. LVN 1 acknowledged all wound care treatment and care after angioplasty should have been included in the POC. On March 2, 2022, Patient 1's record was reviewed. The physician's orders titled, "Post Arterial Follow Up," was reviewed. The physician's orders indicated, "...Home health nurse to visit patient the day of (with-in 2-3 hours of patient been home)…Re-apply dressing pressure, to check for hematoma, check for bleeding, flank discoloration, flank (side of the body between the ribs and the hip) pain...Nurse to advise patient...No bending from the waist, no activity for 24 hours...Home health nurse to visit patient within 24 hours to remove pressure dressing...apply tegaderm dressing...may remove tegaderm dressing after 72 hours...Please see patient for the next 3 consecutive days..." On March 2, 2022, at 11:35 a.m., a concurrent interview and record review was conducted with the Administrator/Director of Patient Care Services (ADM/DPCS) for Patient 1. The ADM/DPCS was not able to find documented evidence in Patient 1's record or in POC of physician's orders for wound care and post angioplasty care. The ADM/DPCS stated the wound care treatment and post angioplasty care should have been included in Patient 1's current POC. The ADM/DPCS acknowledged Patient 1's POC should have been revised and updated. The agency's undated policy and procedure titled, "Physician Orders/Plan of Care," was reviewed. The policy indicated, "...The Plan is updated and is maintained as part of the Agency's clinical record...The Agency's professional staff continuously reviews clinical record to determine adequacy of the plan of treatment and appropriateness of the continuation of care...The Agency's professional staff will review the clinical records on a continuous basis to ensure that each POOC is specific to the patient and that additional orders for services are present in the clinical record..."

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 interview and record review, the agency failed to ensure the frequency of visits in Plan of Care (POC) was followed as ordered by the physician for one of seven sampled patients (Patient 4). This failure had the potential for Patient 4 not to receive the needed care and services. Findings: On March 1, 2022, the record of Patient 4 was reviewed. Patient 4 was admitted to the agency on January 27, 2022, with a primary diagnosis of peripheral vascular disease (PVD- blood circulation disorder arteries or veins). The certification period reviewed was January 27, 2022, through March 27, 2022. Patient 4's record included a physician's order dated February 8, 2022, for "...SN (skilled nursing) frequency visit: QD x 2 days, 1 W 8..." There was one SN visit missed the week of February 8, 2022, through February 12, 2022. On March 2, 2022, at 9:30 a.m., Patient 4's record was reviewed with the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/DPCS acknowledged one SN visit was missed on the week of February 8, 2022, through February 12, 2022. The review of undated agency policy and procedure titled, "Physician Order/Plan of Care" was reviewed. The policy indicated, "...The physician sets up a plan of care, which includes the diagnosis, prognosis,...frequency and type of service...goals to be accomplished, an order for each service...to be provided by the agency..."