Every finding on record at Hcc Healthcare at Home

The following reflects the findings of the California Department of Public Health during the RECERTIFICATION SURVEY conducted on 8/1/23 to 8/9/23. Representing the California Department of Public Health by Federal ID: 11112, Health Facilities Evaluator Nurse. Unduplicated Admissions: 748 Sample Size: 18 Sampled Patients with HOME VISIT: 7 Sampled Patients with NO HOME VISIT: 5 Closed Record Reviewed: 6 The Home Health Agency was determined to have MET all Conditions of Participation. Two Standard deficiencies were issued: G572 and G660

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 observation, interview, and record review, the Home Health Agency (HHA) failed to ensure each patient received home health services as required and written in the Plan of Care (POC) for three of 18 sampled patients (Patients 6, 12, and 18) when: 1. Patient 12 had two missed home visits (HV) with the Physical Therapist (PT) 2, on 7/25/23 and 7/28/23, due to scheduling conflict between Patient 12 and PT 2. This failure resulted in Patient 12 not receiving the physical therapy treatments (examples: gait training, exercises, sit-to-stand transfer techniques and pain management) necessary to help increase Patient 12’s functional independence. 2. Patient 6 had Obstructive Sleep Apnea (OSA, a condition in which a person frequently stops breathing during sleep) and had a Continuous Positive Airway Pressure machine (CPAP, a therapy that keeps a person’s airway open by gently providing air through a mask worn during sleep) that Patient 6 had not used for an undetermined period. The HHA did not assess Patient 6’s use (or non-use) of the CPAP and did not provide the patient and/or caregiver with health education regarding the risks for not using CPAP and the benefits for its consistent use at bedtime. This failure placed Patient 6 at high risk to experience tiredness, low energy, high blood pressure, irregular heartbeats, heart disease, stroke, and inability to remember, think, or make decisions that could interfere with doing everyday activities. 3. Patient 18 had refused Home Visits (HHA) for Skilled Nursing – Wound care, seven times during the certification period of 2/14/23 to 3/13/23, and the HHA did not: a) Educate Patient 18 on the risks and potential adverse outcomes that could result from refusing services, b) Inform Patient 18’s physician of the patient’s refusal for wound care and document this communication, c) Investigate the root cause of Patient 18’s refusal for HVs, and d) Attempt/implement interventions to obtain patient participation with the POC. These failures resulted in Patient 18 to not receive Skilled Nursing services that could have helped in healing her wounds and improve her health, safety, and overall well-being. Patient 18 was transported to the emergency department (ED) on 3/7/23, and subsequently admitted to the hospital on 3/9/23, for an “unknown health complication.” 1. During an interview on 8/4/23 at 1:08 p.m. with the Director of Patient Care Services (DPCS), The DPCS stated Patient 12 was referred by the Podiatrist (a medical specialist who diagnose and treat disorders, diseases, and injuries of the foot, ankle, and lower extremities) for physical therapy due to left and right foot pain. The DPCS stated PT 2 conducted a Start of Care (SOC) assessment on 7/6/23. The DPCS stated Patient 12’s Certification Period (CP) was from 7/6/23 to 9/3/23. During a review of Patient 12’s POC dated 7/6/23, the POC indicated Patient 12’s diagnoses included hypertension (high blood pressure), ingrown toenails, osteoarthritis (painful and stiff joints), right and left ankle and foot pain, and history of falling. The POC indicated Patient 12 was to have physical therapy sessions once a week for 2 weeks, then twice a week for 2 weeks, then once a week. The POC indicated “Physical Therapy Interventions for…safe transfers, gait training, walker use when walking, strengthening/exercise program for legs and feet, assessing level of pain and effectiveness of pain medication, energy conservation, managing fatigue, and falls prevention.” During a concurrent record review and interview on 8/4/23 at 1:20 p.m., with the DPCS, Patient 12’s physical therapy “Home Visit (HV)” reports for 7/2023, indicated Patient 12 had physical therapy HVs on 7/6/23, 7/13/23, 7/18/23, and 7/21/23. The DPCS stated “Patient 12 had two missed HVs, on 7/25/23 and 7/28/23… Patient 12 had declined the HV on 7/25/23 because she had a doctor’s appointment, and the scheduled 7/25/23 HV were missed because of scheduling conflict between Patient 12’s availability against PT 2’s workload.” The DPCS stated, the Standard of Practice (SOP) for missed HV was for the clinician to attempt to reschedule a “make-up” HV with the patient or his/her caregiver. The DPCS stated, “This was not done. I could not find documentation in PT 2’s report that he attempted to schedule a make-up HV with Patient 12 or her caregiver.” During a telephone interview on 8/4/23 at 1:46 p.m. with PT 2, PT 2 admitted he did not do Patient 12’s HV on 7/25/23. PT 2 stated he was also unable to re-schedule a make-up HV with Patient 12 because it was hard for him to get back to Patient 12’s residence that same day. PT 2 stated, “If HVs are missed, there would be missed opportunity for Patient 12 to do strengthening exercises and increased risk to fall.” When asked if he informed the DPCS and Patient 12’s physician of the 2 missed HVs for Patient 12, PT 2 stated he had not. During a review of the HHA’s Policy and Procedure (P&P) titled, “MISSED VISITS,” dated 10/2019, the P&P indicated “PURPOSE: To ensure that missed visits are documented and does not affect the quality of patient care. POLICY: Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be re-scheduled the same week if possible… PROCEDURE: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be reconsidered a missed visit… 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. 5. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the POC and make adjustments to the plan of care with input from the patient and physician.” 2. During a home visit observation and interview, on 8/8/23 at 10:20 a.m., with Occupational Therapist (OT), inside Patient 6’s apartment, Patient 6 was observed lying in her hospital bed. Patient 6 was observed to be overweight and unable to independently shift her position. Patient 6 was observed with oxygen at three liters per minute per nasal cannula (a lightweight 2-prong tube which are placed in the nostrils to deliver a mixture of air and oxygen to a person). A small CPAP machine was observed on top of a box with other household items. When asked if Patient 6 had been using the CPAP machine, Patient 6’s caregiver (CG) stated, “She never used it… she tells us it freaks her out!” The CG stated, “I don’t remember anyone (from the HHA) telling us anything about that machine (pointed at the CPAP machine) … Patient gets restless and stays awake most nights and sleeps all day. She had been very confused lately and seeing things… saying her pillow is a crocodile…” During a review of Patient 6’s “Outcome and Assessment Information Set” (OASIS, a patient-specific, standardized assessment used to plan a patient’s care and measure quality of care/services) dated 7/11/23, the OASIS indicated Patient 6’s diagnoses included Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease (COPD, a lung disease that makes it hard to breathe because air doesn't flow easily in and out of a person’s lungs), morbid (severe) obesity (excessive body fat due to excess calories), dependence on supplemental oxygen, and panic disorder with hallucinations (hearing, seeing, feeling, smelling, or even tasting things that are not real). The OASIS (Respiratory – page 19 of 32) indicated “CPAP r/t (related to) OSA.” During a concurrent record review and interview, on 8/8/23 at 2:40 p.m., with the DPCS, the 45 Skilled Nursing (SN) interventions listed in the OASIS dated 7/11/23, was read and reviewed with the DPCS. The DPCS confirmed there was no documented evidence RN 2 had assessed Patient 6’s use (or non-use) of the CPAP machine nor provided the patient and/or caregiver with health education regarding the risks for not using CPAP therapy and the benefits for its use at bedtime. During a concurrent record review and interview, on 8/8/23 at 2:45 p.m., with the DPCS, the Skilled Nursing Visit report dated 8/4/23, done by LVN 1, did not address Patient 6’s CPAP. The DPCS confirmed there was no documented evidence LVN 1 had assessed Patient 6’s use (or non-use) of the CPAP, nor provided the patient and/or caregiver with health education regarding the risks for not using CPAP and the benefits for its consistent use at bedtime. During a review of an online article titled, “ADVANTAGES OF A CPAP MACHINE”, dated 11/09/2021 and retrieved from https://my.clevelandclinic.org/health/treatments/22043-cpap-machine, the article indicated “ CPAP machine is one of the most common treatments for sleep apnea. It keeps the airways open while a person is sleeping so one can receive the oxygen needed for optimal function. CPAP machines can significantly improve sleep quality and reduce risk for several health issues, including heart disease and stroke. CPAP machines are used to treat both obstructive and central sleep apnea. In both disorders, the breathing is interrupted during the sleep cycle. This can occur hundreds of times in a single night, leading to a lack of oxygen and a higher risk for high blood pressure, heart disease, stroke, diabetes, and other health concerns. A CPAP machine helps keep the airways open by delivering continuous air through the nose and mouth. What are the advantages of a CPAP machine? CPAP machines prevent breathing interruptions caused by sleep apnea. These devices also eliminate harmful sleep apnea side effects. Notable CPAP machine benefits include improved sleep quality, lowers risk of heart attack and stroke, reduces daytime sleepiness, and possible improvement in sugar management in people with diabetes.” 3. During a record review of Patient 18’s undated “Patient Information (PI),” the PI indicated Patient 18 was referred to the HHA on 12/12/22 for Skilled Nursing (SN) wound care. Patient 18’s Start of Care (COC) was 12/16/22, with the SN Home Visits (HV) set at a frequency of once a week for 1 week, then two times a week for 8 weeks. The POC dated 12/16/22 indicated Patient 18’s SN interventions included wound care to right and left leg open and weeping wounds and application of compression wraps. During a concurrent record review and interview on 8/8/23 at 3:30 p.m. with the DPCS, the DPCS stated Patient 18 had refused SN HV at least seven times, due to Patient 18’s appointments at the wound clinic or for not feeling well. The DPCS stated Patient 18 refused SN HVs on 2/14, 2/17, 2/21, 2/24, 2/28, 3/3, and 3/7/23. The DPCS stated LVN had called Patient 18 several times to set an appointment for a HV, but Patient 18 consistently declined. The DPCS stated that on 3/7/23, LVN 1 had called Patient 18 to schedule a HV and the patient refused and informed LVN 1 she was going straight to the emergency room (ER) and have the ER take care of all her issues. The DPCS stated, Patient 18 was admitted to the hospital on 3/9/23 for an “unknown health complication." When asked if Patient 18 was educated on the risks and potential adverse outcomes that could result from refusing wound care, the DPCS stated there was no documentation to show that had been done. During a review of Patient 18’s “Missed Visit Form (MVF)” dated 2/21, 2/24, 2/28, 3/3, and 3/7/23, the MVFs indicated Patient 18’s physician was not notified of the patient’s multiple refusals for a SN HVs. During an interview on 8/8/23 at 3:35 p.m. with the DPCS, the DPCS stated the HHA had not done a root cause analysis to identify trends or patterns for missed HVs or refused HVs, had not educated patients or caregivers on the risks and potential adverse outcomes that could result from refusing services, had not documented its communication with physicians who were responsible for their patient’s home health plan of care, and had not attempted interventions in order to obtain patient participation with the plan of care. During a review of the HHA’s Policy and Procedure (P&P) titled, “MISSED VISITS” revised date of 10/2019, indicated “PURPOSE: To ensure that missed visits are documented and does not affect the quality of patient care. POLICY: Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible… PROCEDURE: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be reconsidered a missed visit… 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. 5. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the POC and make adjustments to the plan of care with input from the patient and physician.”

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Governing Body (GB, a group of designated persons who assume full legal authority and responsibility for the Home Health Agency’s [HHA] overall management and operation, the provision of all home health services, and its quality assessment and performance improvement program) failed to ensure an ongoing program for quality improvement and patient safety are implemented, and maintained, for three of 18 sampled patients (Patients 6, 12, and 18) when: 1. Patient 12 had two missed home visits (HV) with the Physical Therapist (PT) 2, on 7/25/23 and 7/28/23, due to scheduling conflict between Patient 12 and PT 2. This failure resulted in Patient 12 not receiving the physical therapy treatments (examples: gait training, exercises, sit-to-stand transfer techniques and pain management) necessary to help increase Patient 12’s functional independence. (Refer to G572) 2. Patient 6 had Obstructive Sleep Apnea (OSA, a condition in which a person frequently stops breathing during sleep) and had a Continuous Positive Airway Pressure machine (CPAP, a therapy that keeps a person’s airway open by gently providing air through a mask worn during sleep) that Patient 6 had not used for an undetermined period. The HHA did not assess Patient 6’s use (or non-use) of the CPAP and did not provide the patient and/or caregiver with health education regarding the risks for not using CPAP and the benefits for its consistent use at bedtime. This failure placed Patient 6 at high risk to experience tiredness, low energy, high blood pressure, irregular heartbeats, heart disease, stroke, and inability to remember, think, or make decisions that could interfere with doing everyday activities. (Refer to G572) 3. Patient 18 had refused Home Visits (HHA) for Skilled Nursing – Wound care, seven times during the certification period of 2/14/23 to 3/13/23, and the HHA did not: a) Educate Patient 18 on the risks and potential adverse outcomes that could result from refusing wound care, b) Inform Patient 18’s physician of the patient’s refusal for wound care and document this communication, c) Investigate the root cause of Patient 18’s refusal for HVs, and d) Attempt/implement interventions to obtain patient participation with the POC. These failures resulted in Patient 18 to not receive Skilled Nursing services that could have helped in healing her wounds and improve her health, safety, and overall well-being. Patient 18 was transported to the emergency department (ED) on 3/7/23, and subsequently admitted to the hospital on 3/9/23, for an “unknown health complication.” (Refer to G572) 1. During a review of Patient 12’s POC dated 7/6/23, the POC indicated Patient 12’s diagnoses included hypertension (high blood pressure), ingrown toenails, osteoarthritis (painful and stiff joints), right and left ankle and foot pain, and history of falling. The POC indicated Patient 12 was to have physical therapy sessions once a week for 2 weeks, then twice a week for 2 weeks, then once a week. The POC indicated “Physical Therapy Interventions for…safe transfers, gait training, walker use when walking, strengthening/exercise program for legs and feet, assessing level of pain and effectiveness of pain medication, energy conservation, managing fatigue, and falls prevention.” During a concurrent record review and interview on 8/4/23 at 1:20 p.m. with the DPCS, Patient 12’s physical therapy “Home Visit (HV)” reports for 7/2023, indicated Patient 12 had physical therapy HVs on 7/6/23, 7/13/23, 7/18/23, and 7/21/23. The DPCS stated “Patient 12 had two missed HVs, on 7/25/23 and 7/28/23… Patient 12 had declined the HV on 7/25/23 because she had a doctor’s appointment, and the scheduled 7/25/23 HV were missed because of scheduling conflict between Patient 12’s availability against PT 2’s workload.” The DPCS stated, the Standard of Practice (SOP) for missed HV was for the clinician to attempt to reschedule a “make-up” HV with the patient or his/her caregiver. The DPCS stated, “This was not done. I could not find documentation in PT 2’s report that he attempted to schedule a make-up HV with Patient 12 or her caregiver.” During a telephone interview on 8/4/23 at 1:46 p.m. with PT 2, PT 2 admitted he did not do Patient 12’s HV on 7/25/23. PT 2 stated he was also unable to re-schedule a make-up HV with Patient 12 because it was hard for him to get back to Patient 12's residence that same day. PT 2 stated, “If HVs are missed, there would be missed opportunity for Patient 12 to do strengthening exercises and increased risk to fall.” When asked if he informed the DPCS and Patient 12’s physician of the 2 missed HVs for Patient 12, PT 2 stated he had not. During a review of the HHA’s Policy and Procedure (P&P) titled, “MISSED VISITS,” dated 10/2019, the P&P indicated “PURPOSE: To ensure that missed visits are documented and does not affect the quality of patient care. POLICY: Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be re-scheduled the same week if possible… PROCEDURE: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be reconsidered a missed visit… 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. 5. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the POC and make adjustments to the plan of care with input from the patient and physician.” 2. During a home visit observation and interview, on 8/8/23 at 10:20 a.m., with Occupational Therapist (OT), inside Patient 6’s apartment, Patient 6 was observed lying in her hospital bed. Patient 6 was observed to be overweight and unable to independently shift her position. Patient 6 was observed with oxygen at three liters per minute per nasal cannula (a lightweight 2-prong tube which are placed in the nostrils to deliver a mixture of air and oxygen to a person). A small CPAP machine was observed on top of a box with other household items. When asked if Patient 6 had been using the CPAP machine, Patient 6’s caregiver (CG) stated, “She never used it… she tells us it freaks her out!” The CG stated, “I don’t remember anyone (from the HHA) telling us anything about that machine (pointed at the CPAP machine) … Patient gets restless and stays awake most nights and sleeps all day. She had been very confused lately and seeing things… saying her pillow is a crocodile…” During a review of Patient 6’s “Outcome and Assessment Information Set” (OASIS, a patient-specific, standardized assessment used to plan a patient’s care and measure quality of care/services) dated 7/11/23, the OASIS indicated Patient 6’s diagnoses included Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease (COPD, a lung disease that makes it hard to breathe because air doesn't flow easily in and out of a person’s lungs), morbid (severe) obesity (excessive body fat due to excess calories), dependence on supplemental oxygen, and panic disorder with hallucinations (hearing, seeing, feeling, smelling, or even tasting things that are not real). The OASIS (Respiratory – page 19 of 32) indicated “CPAP r/t (related to) OSA.” During a concurrent record review and interview, on 8/8/23 at 2:40 p.m., with the DPCS, the 45 Skilled Nursing (SN) interventions listed in the OASIS dated 7/11/23, was read and reviewed with the DPCS. The DPCS confirmed there was no documented evidence RN 2 had assessed Patient 6’s use (or non-use) of the CPAP machine nor provided the patient and/or caregiver with health education regarding the risks for not using CPAP therapy and the benefits for its use at bedtime. During a concurrent record review and interview, on 8/8/23 at 2:45 p.m. with the DPCS, the Skilled Nursing Visit report dated 8/4/23 done by LVN 1 did not address Patient 6’s CPAP. The DPCS confirmed there was no documented evidence LVN 1 had assessed Patient 6’s use (or non-use) of the CPAP, nor provided the patient and/or caregiver with health education regarding the risks for not using CPAP and the benefits for its consistent use at bedtime. During a review of an online article titled, “ADVANTAGES OF A CPAP MACHINE”, dated 11/09/2021 and retrieved from https://my.clevelandclinic.org/health/treatments/22043-cpap-machine, the article indicated “ CPAP machine is one of the most common treatments for sleep apnea. It keeps the airways open while a person is sleeping so one can receive the oxygen needed for optimal function. CPAP machines can significantly improve sleep quality and reduce risk for several health issues, including heart disease and stroke. CPAP machines are used to treat both obstructive and central sleep apnea. In both disorders, the breathing is interrupted during the sleep cycle. This can occur hundreds of times in a single night, leading to a lack of oxygen and a higher risk for high blood pressure, heart disease, stroke, diabetes, and other health concerns. A CPAP machine helps keep the airways open by delivering continuous air through the nose and mouth. What are the advantages of a CPAP machine? CPAP machines prevent breathing interruptions caused by sleep apnea. These devices also eliminate harmful sleep apnea side effects. Notable CPAP machine benefits include improved sleep quality, lowers risk of heart attack and stroke, reduces daytime sleepiness, and possible improvement in sugar management in people with diabetes.” 3. During a record review of Patient 18’s undated “Patient Information (PI),” the PI indicated Patient 18 was referred to the HHA on 12/12/22 for Skilled Nursing (SN) wound care. Patient 18’s Start of Care (COC) was 12/16/22, with the SN Home Visits (HV) set at a frequency of once a week for 1 week, then two times a week for 8 weeks. The POC dated 12/16/22 indicated Patient 18’s SN interventions included wound care to right and left leg open and weeping wounds and application of compression wraps. During a concurrent record review and interview on 8/8/23 at 3:30 p.m. with the DPCS, the DPCS stated Patient 18 had refused SN HV at least seven times, due to Patient 18’s appointments at the wound clinic or for not feeling well. The DPCS stated Patient 18 refused SN HVs on 2/14, 2/17, 2/21, 2/24, 2/28, 3/3, and 3/7/23. The DPCS stated LVN had called Patient 18 several times to set an appointment for a HV, but Patient 18 consistently declined. The DPCS stated that on 3/7/23, LVN 1 had called Patient 18 to schedule a HV and the patient refused and informed LVN 1 she was going straight to the emergency room (ER) and have the ER take care of all her issues. The DPCS stated, Patient 18 was admitted to the hospital on 3/9/23 for an “unknown health complication. When asked if Patient 18 was educated on the risks and potential adverse outcomes that could result from refusing wound care, the DPCS stated there was no documentation to show that had been done. During a review of Patient 18’s “Missed Visit Form (MVF)” dated 2/21, 2/24, 2/28, 3/3, and 3/7/23, the MVFs indicated Patient 18’s physician was not notified of the patient’s multiple refusals for a SN HVs. During an interview on 8/8/23 at 3:35 p.m. with the DPCS, the DPCS stated the HHA had not done a root cause analysis to identify trends or patterns for missed HVs or refused HVs, had not educated patients or caregivers on the risks and potential adverse outcomes that could result from refusing services, had not documented its communication with physicians who were responsible for their patient’s home health plan of care, and had not attempted interventions in order to obtain patient participation with the plan of care. The DPCS was unable to provide documented evidence she and the clinician evaluated the appropriateness of the POC, nor adjust Patient 18’s POC with input from the patient and physician. During a review of the HHA’s Policy and Procedure (P&P) titled, “MISSED VISITS” revised date of 10/2019, indicated “PURPOSE: To ensure that missed visits are documented and does not affect the quality of patient care. POLICY: Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible… PROCEDURE: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be reconsidered a missed visit… 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. 5. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the POC and make adjustments to the plan of care with input from the patient and physician.” During a phone interview with Confidential Person (CP) 1, on 8/8/23 at 5:00 p.m., CP 1 stated, “The GB are in (Out-of-State) … This HHA has had five executive directors over the past 2 to 3 years and the operations of this agency had been poor… Many problems, poor communication trickles down from corporate down to staff… there had been patient care issues that had not been looked at…” 3. During an interview, on 8/8/23 at 3:35 p.m., with the DPCS, the DPCS stated the HHA had not done a root cause analysis to identify trends or patterns for missed HVs or refused HVs, had not educated patients or caregivers on the risks and potential adverse outcomes that could result from refusing services, had not documented its communication with physicians who were responsible for their patient’s home health plan of care, and had not attempted interventions in order to obtain patient participation with the plan of care. The DPCS was unable to provide documented evidence she and the clinician evaluated the appropriateness of the POC, nor adjust Patient 18’s POC with input from the patient and physician.