Every finding on record at Health Care Solutions Services, Inc

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Partial Extended Recertification surveys. Representing the California Department of Public Health: Surveyors 39539, HFEN; 31929, HFEN; and 39210, HFEN. The survey team entered the HHA on 8/1/23 at 0900 hours. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: HHA: Home Health Agency DPCS: Director of Patient Care Services

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan was updated at least every two years. This created the potential risk of not meeting the health, safety, and security needs of their staff and the patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. Review of the agency's Professional Advisory Board Meeting minutes dated 3/17/22, showed the emergency preparedness plan was briefly reviewed. However, there was no documented evidence showing the agency's Emergency Preparedness plan was updated at least every two years. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS stated they reviewed the plan for emergency preparedness but did not update the plan. The Administrator/DPCS was informed and acknowledged the findings.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their comprehensive emergency preparedness program was facility based and community-based risk assessment, utilizing an all-hazards approach. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The agency's Emergency Preparedness Plan (undated) showed the emergency plan will be detailed to guide the agency during an emergency. However, the agency's emergency preparedness plan failed to include a facility and community-based risk assessments and strategies for addressing hazards or emergency events identified by the facility and community risk assessments. On 8/7/23 at 1005 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their comprehensive emergency preparedness program addressed the patient population, including the plans to continue operations. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The emergency preparedness plan (undated) showed an objective to assess the patient's home environment for safely and assist them to a safe environment. However, the plan failed to address the patient population, including the types of services the agency has the ability to provide in an emergency, continuity of operations, including delegations of authority and succession plans. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their emergency preparedness plan included a process for cooperation and collaboration with the local, tribal, regional, state, and federal emergency preparedness officials. This created the potential risk of not maintaining an integrated response during a disaster or emergency situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. Review of the Emergency Preparedness Plan (undated) showed in the event of an evacuation, arrangements will be able through the county emergency planners for transport. However, the agency's emergency preparedness plan failed to describe the agency's process in engaging and coordinating with the local healthcare systems, local and state health departments, and federal agency staff. On 8/8/23 at 1005 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their comprehensive emergency preparedness program based on the risk assessment was updated at least every two years. This created the potential risk of not meeting the health, safety, and security needs of their staff and the patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. Review of the agency's Professional Advisory Board Meeting minutes dated 3/17/22, showed the emergency preparedness plan was briefly reviewed and updated the phone triage tree. However, there was no documented evidence the agency's emergency preparedness plan was based on the risk assessment and the communication plan were updated at least every two years. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to inform the state and local emergency officials about the patients in need of evacuation from their residences due to an emergency situation. This created the potential risk of not meeting the health, safety, and security needs of their staff and the patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness and plan was conducted on 8/4/23. Review of the agency's Professional Advisory Board Meeting minutes dated 3/17/22, showed the emergency preparedness plan was briefly reviewed. The agency's Emergency Preparedness Plan (undated) showed if the patient is unharmed, but the home is damaged or unsafe and the telephone system is working, contact family or friends that the patient may request and make arrangements for the patient's transportation and contact the emergency supervisor for arrangements to be made through county emergency for transportation to an alternate care facility if other arrangements cannot be made. In addition, if a patient is injured and needs transport, contact an emergency supervisor for arrangements to be made through the county emergency planner for transport to a hospital/ emergency room/ triage site, depending on need. However, the agency's emergency preparedness plan failed to describe the procedure to inform state and local emergency preparedness officials about patients in need of evacuation from their residences due to an emergency situation based on the patient's medical, psychiatric condition, and home environment. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to follow up with the on-duty staff and patients, to determine the services needed and procedures to inform the state and local officials of any on-duty staff or patients they are unable to contact. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The agency's Emergency Preparedness Plan (undated) showed the office manager will notify the secretary and then each will notify persons listed below them on the calling list. If they are unable to reach an employee on the telephone, they will proceed to the next listed person on the list. The office manager and secretary will call the office and list the employees available for assistance then come to the office. Upon arrival, every five minutes, Office Manager and Secretary will try those employees not found with the first call attempt and notify the Disaster Supervisor of any other employees found to be available on standby. However, the agency's Emergency Preparedness Plan did not include the procedures to follow up with any on-duty staff or patients they are unable to contact, or procedures to communicate with the state and local officials of any on duty staff or patients they are unable to contact. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included a system of medication documentation that preserves, protects, and secures the patient information, and maintains availability of the records. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The agency's emergency preparedness plan (undated) showed the administrator will collect, analyze key information and maintain documents for demobilization. However, the agency's emergency preparedness plan did not include the system of medical documentation that preserves the patient information, protects confidentiality of patient information, and secures and maintains availability of the records. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan addressed the use of the volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The agency's emergency preparedness plan (undated) showed the chief clinical officer will have power to assign staff to specific tasks, and with the coordinator will work with appointed team leaders to assist in identifying patients affected by the emergency and assigning clinical staff members to check on those patients. However, the agency's emergency preparedness plan did not include the use of the volunteers in an emergency, and other emergency staffing strategies to address surge needs, including which external staffing agencies to be used, or the role for the integration of State and Federal designated health care professionals to address surge needs during an emergency. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness communication plan was updated at least every two years, creating the increased risk of not addressing the care needs of the patients during the emergency events. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The emergency preparedness communication plan failed to show documented evidence the plan was updated every two years. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the updated name and contact information of the staff, entities provided services under agreement, patients' physician, and volunteers. This failure had the potential to negatively impact the patients' care needs during the emergency events. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The agency's emergency preparedness plan showed the agency will keep and maintain a current list of contact information for staff, staff family members, vendors, emergency services, hospitals, and other appropriate community resources. However, the agency did not have a current contact information for staff, staff family members, vendors, emergency services, hospitals, or other community resources available for review. In addition, the agency's emergency preparedness plan did not include the addresses, names, and contact information of the staff, entities providing services under agreement, patients' physician, and volunteers. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness plan included the contact's name and information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. This failure had the potential to negatively impact the patients' care needs during the emergency events. Findings: Review of the agency's emergency preparedness plan was conducted on 8/8/23. The agency's emergency preparedness plan did not include the contact information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/ DPCS. The Administrator/ DPCS was informed and acknowledged the findings.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness plan included the method for sharing the information and medical documentation for the HHA's patients with other health providers to maintain the continuity of care, creating the increased risk of not providing appropriate, consistent, and quality care to the patients during the emergency events. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The agency's emergency preparedness communication plan did not include the method for sharing the information and medical documentation for the HHA's patients with other health providers to maintain the continuity of care. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness training and testing program were updated at least every two years, creating the increased risk of not addressing the care needs of the patients during emergency events. Findings: Review of the agency's emergency preparedness plan was conducted on 8/4/23. The agency's emergency preparedness plan (undated) did not address the requirement for the emergency preparedness training and testing program that should be updated at least every two years. In addition, the agency was unable to provide documented evidence the emergency preparedness training and testing program were in place. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS stated they reviewed and confirmed the emergency preparedness training and testing program were not updated. The Administrator/DPCS was informed and acknowledged the findings.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure initial training in the emergency preparedness program was provided to all new staff, existing staff, volunteers, and contracted individuals providing services under arrangement and the documentation of all the emergency preparedness training was maintained. This failure created the risk of the HHA's staff not knowing what to do in case of emergency. Findings: Review of the agency's emergency preparedness policy was conducted on 8/4/23. The agency's emergency preparedness plan did not address the requirement to provide initial emergency preparedness training to new staff, existing staff the volunteers and contracted individuals. In addition, there was no documented evidence the initial emergency preparedness training was provided at least every two years, or the documentation to demonstrate staff knowledge of emergency procedures were provided to the new staff, existing staff, volunteers, or contracted individuals. On 8/7/23 at 1005 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS surveys. Representing the California Department of Public Health: Surveyors 39539, HFEN; 31929, HFEN; and 39210, HFEN. The survey team entered the Home Health Agency on 8/1/23 at 0900 hours. The survey team reviewed five active and two closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL: Activities of Daily Living BID: twice a day CDPH: California Department of Public Health CEO: Chief Executive Officer CHHA: Certified Home Health Aide cm: centimeter(s) DPCS: Director of Patient Care Services HHA: Home Health Agency HR: Human Resource mcg: microgram(s) mg: milligram(s) MSW: Medical Social Worker OASIS: Outcome and Assessment Information Set OT: Occupational Therapy/Therapist P&P: policy and procedure PAC: Professional Advisory Committee PCG: Patient Care Giver PO: by mouth POC: Plan of Care PRN: as needed PT: Physical Therapy/Therapist Q: Every QAPI: Quality Assurance and Performance Improvement QD: Every day RN: Registered Nurse SN: Skilled Nurse SOC: Start of Care ST: Speech Therapy/Therapist Stage 2 pressure injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. TID: three times a day UTI: Urinary Tract Infection W: week WFL: within functional limit WNL: within normal limit

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the complaints for one of seven sampled patients (Patient 3) and three nonsampled patients (Patients A, B, and C) were thoroughly investigated, creating the risk not providing quality of care and services to these patients. Findings: The agency’s P&P titled Complaint/Grievance Process dated 2009 showed the organization personnel receiving the complaint will discuss, verbally and writing, the grievance with the Clinical Supervisor within 5 days of the alleged grievance. The Clinical Supervisor will investigate the grievance within five days after the receipt of such grievance and will make every effort to resolve the grievance to the patient’s satisfaction. Response to the patient regarding the complaint will occur within 10 days of the receipt. If the grievance cannot be resolved to the patient’s satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator. The grievance must state the problem or action alleged and the date the Clinical supervisor was notified. The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within 10 days of notification of failure to resolve the complaint. Review of the agency’s complaint documents showed the following information: a. The Complaint Form dated 10/9/19, showed Patient A called to inform the office that the SN had not showed up yet. Documentation showed Patient A was expecting the nurse "today." Documentation showed the action taken to resolve the complaint included the SN was called to inform that the patient was expecting the SN "today." The SN was to call the patient and inform when the SN would be visiting. b. The Complaint Form dated 2/12/21, showed the family member for Patient B was still waiting for the SN to call for the date and time of the visit. Documentation showed the resolution included the SN was instructed to call the family member at least a day to make an appointment. c. The Complaint Form dated 5/6/21, showed a call was received from the family member of Patient B requesting to change the SN. Documentation showed the family member stated the SN was always in a hurry. Documentation showed the action taken to resolve the complaint was to re-staff to another SN. d. The Complaint Form dated 8/16/22, showed a call was received from the family member of Patient 3 reporting the PT had not showed up yet; and the PT had not called to let the family member know the PT would be late. Documentation showed the action taken to resolve the complaint was that the PT was notified to call the patient/family member if running late or unable to make it to the appointment. e. The Complaint Form dated 3/31/23, showed the family member of Patient C called to inform the office that the PT had not showed up at the scheduled time. Documentation showed the action taken to resolve the complaint included the office staff informed the PT that the patient and the family member was expecting the PT today; and the PT would call the family member to inform the arrival time. Documentation showed the action plan to prevent reoccurrence of the incident included the PT would call the patient/family if running late prior to scheduled time. * However, there were no documented evidence of the agency conducted a thorough investigation by interviewing the staff for the above grievances. On 8/8/23 at 0933 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed of the findings.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the resolution of the complaints were provided in writing for one of seven sampled patients (Patient 3) and three nonsampled patients (Patients A, B, and C), creating the risk of violating the patient's rights and not addressing the grievances for the patients. Findings: The agency’s P&P titled Complaint/Grievance Process dated 2009 showed the resolution information will be communicated in writing to the patient or his/her representative filing the complaint. Review of the agency’s complaint documents showed the following information: a. The Complaint Form dated 10/9/19, showed Patient A called to inform the office that the SN had not showed up yet. Documentation showed Patient A was expecting the nurse "today." Documentation showed the action taken to resolve the complaint included the SN was called to inform that the patient was expecting the SN "today." Documentation showed the SN was to call the patient and inform when the SN would be visiting. b. The Complaint Form dated 2/12/21, showed the family member for Patient B was still waiting for SN to call for the date and time of the visit. Documentation showed the resolution included SN was instructed to call the family member at least a day to make an appointment. c. The Complaint Form dated 5/6/21, showed a call was received from the family member of Patient B requesting to change the SN. Documentation showed the family member stated the SN was always in a hurry. Documentation showed the action taken to resolve the complaint was to re-staff to another SN. d. The Complaint Form dated 8/16/22, showed a call was received from the family member of Patient 3 reporting the PT had not showed up yet; and the PT had not called to let the family member know the PT will be late. Documentation showed the action taken to resolve the complaint was PT was notified to call the patient/family member if running late or unable to make it to the appointment. e. The Complaint Form dated 3/31/23, showed the family member of Patient C called to inform the office that the PT had not showed up at scheduled time. Documentation showed the action taken to resolve the complaint included the office staff informed PT that the patient and the family member was expecting the PT today; and PT will call the family member to inform the arrival time. Documentation showed the action plan to prevent reoccurrence of the incident included PT will call patient/family if running late prior to scheduled time. * However, there were no documented evidence the agency had communicated in writing to the patients or his/her representatives filing the complaint about the resolution information as per the agency’s P&P. On 8/8/23 at 0933 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed of the findings.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed accurately and consistently with the patients’ immediate needs for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7). These failures created the risk of not identifying and addressing the care needs timely for these patients. #. Review of Patient 6's closed clinical record was initiated on 8/1/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification periods from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. The Start of Care OASIS dated 1/21/22, showed no documented evidence the patient’s heart sound, capillary refill, oxygen saturation, and education level was completed. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on 8/1/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification periods from 4/19/23 to 6/17/23 and 6/18/23 to 8/16/23. The Start of Care OASIS dated 4/19/23, showed the patient had a Stage 2 pressure injury on the left and right buttocks. Documentation showed the left buttock had a wound measurement of 1.5 cm (length) x 1.3 cm (width) and the right buttock had a wound measurement of 1.3 cm x 1.4 cm. However, there was no documented evidence the wound depth was measured on the Stage 2 pressure injury on the left and right buttocks. In addition, there was no documented evidence the patient’s education level was completed. On 8/8/23 at 0933 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 2's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 1/7/23. The patient was certified for home health services from 7/6/23 to 9/3/23. The SOC OASIS dated 1/7/23, showed no documented evidence the patient’s education level, pulse, or breath sounds was completed. On 8/8/23 at 0915 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding. #. Review of Patient 4's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/13/23. The patient was certified for home health services during the certification periods from 4/13/23 to 6/11/23 and 6/12/23 to 8/11/23. The Start of Care OASIS dated 4/13/23, showed no documented evidence the patient’s education level was completed. On 8/8/23 at 0935 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding. #. Review of Patient 7's closed clinical record was initiated on 8/2/23. The clinical record showed the SOC was 3/15/23. The patient was certified for home health services during the certification periods from 3/15/23 to 5/13/23 and 5/14/23 to 7/12/23. The Start of Care OASIS dated 3/15/23 , showed no documented evidence the patient’s education level or prior hospitalizations was completed. On 8/8/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding. Review of the agency’s P&P titled Initial and Comprehensive Assessment dated 2009 showed the assessment will be patient specific and comprehensive to include the patient’s need for home health care, rehabilitative care, social services, and discharge planning. The assessment will also include the exact use of the current versions of the Outcomes and Assessment Information Set (OASIS). 1. Review of Patient 1's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 2/7/22. The patient was certified for home health services during the certification period from 6/7/23 to 8/5/23. Review of the SOC OASIS dated 2/7/23, showed the Cognitive Pattern was assessed. There was a check mark documented next to “No” showing the patient was rarely/never understood. However, review of the Mental Status assessment revealed a note showing the patient was alert and oriented x 3, very articulate, and had the ability to express feelings clearly and coherently which was inconsistent with the previous assessment. Review of the Cardiopulmonary section showed the SN had assessed the patient to have edema. However, there was no documented evidence specifying the location and characteristics of the patient’s edema. On 8/8/23 at 0905 hours, an interview and concurrent clinical record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledge the finding. 2. Review of Patient 3's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification periods from 4/19/23 to 6/17/23 and 6/18/23 to 8/16/23. Review of the SOC OASIS dated 4/19/23, showed the Cognitive Pattern was assessed. There was a check mark documented next to “No” showing the patient was rarely/never understood. However, review of the Mental Status assessment revealed a note showing the patient was alert and oriented x 3 and was calm and cooperative which was inconsistent with the previous assessment. Further review of the SOC OASIS showed no documented evidence the Home Safety Assessment section was assessed. On 8/8/23 at 0916 hours, an interview and concurrent clinical record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledge the finding.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were updated to reflect the current medications, include all the medication side effects, actual or potential drug interactions, and duplicate drug therapy for three of seven sampled patients (Patients 3, 4, and 6). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification periods from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. According to Lexi-Comp's pharmacology website, concomitant use of opioids with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. The Medication Profile, for the certification 7/20/22 to 9/17/22, showed the patient’s medications included Xanax (antianxiety) 0.25 mg one half tablet once PRN for anxiety; alprazolam (generic name for Xanax) 0.25 mg one tablet PO TID PRN for anxiety, agitation, and restlessness; and hydrocodone/acetaminophen 5-325 mg one tablet PO Q eight hours PRN for severe pain. Documentation showed no medication related issues identified. However, there was no documented evidence the agency had identified the potential drug interaction for these medications. In addition, the medication profile included two different information for the administration of Xanax/alprazolam. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 4's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/13/23. The patient was certified for home health services during the certification periods from4/13/23 to 6/11/23 and 6/12/23 to 8/10/23 On 8/2/23 at 0800 hours, a joint home visit was conducted with LVN 1 to Patient 4’s home. Review of the patient’s medications with LVN 1 showed the patient was taking Aspirin 81 mg two tablets PO QD instead of Aspirin 81 mg one tablet PO QD as written in the medication profile. On 8/2/23 at 0835 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 verified the above findings. On 8/8/23 at 0945 hours, the Office Clerk was informed and acknowledged the findings. Review of the agency’s P&P titled Medication Profile dated 2018 showed patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, and when care is resumed after a patient has been placed on hold. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy omissions and unclear information. 1. Review of Patient 3's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification periods from 4/19/23 to 6/17/23 and 6/18/23 to 8/16/23. On 8/2/23 at 1445 hours, a joint home visit was conducted with PT 1 to Patient 3’s home. Review of the patient’s medications with PT 1 showed the patient was taking cholecalciferol (supplement) 125 mcg PO QD, magnesium (supplement) 500 mg PO TID, and prednisone (steroid) 10 mg PO QD which were not included in the patient’s medication profile. The patient was also taking metoprolol (antihypertensive) 50 mg PO BID instead of 100 mg as written in the medication profile. Further review of the Medication Profiles for both certification periods showed the medications were appraised for possible adverse effects and reactions, including cogent drug interactions, ineffectual drug therapy, redundant drug therapy, serious side effects, and non-compliance with drug therapy. However, there was no documented evidence showing which adverse effects, drug interactions, and side effects were identified. On 8/8/23 at 0916 hours, an interview and concurrent clinical record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledge the finding.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the updated comprehensive assessments were completed accurately and consistently with the patients’ immediate needs for five of seven sampled patients (Patients 1, 2, 4, 5, and 6). These failures created the risk of not identifying and addressing the care needs timely for these patients. #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification periods from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. The Recertification OASIS dated 7/15/22, showed no documented evidence the patient’s oxygen saturation, heart sounds, capillary refill, and education level was completed. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on 8/1/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification periods from 4/19/23 to 6/17/23 and 6/18/23 to 8/16/23. The Recertification OASIS dated 6/16/23, showed the patient had a Stage 2 pressure injury on the right buttock. Documentation showed the right buttock had a wound measurement of 0.6 cm x 0.5 cm. However, there was no documented evidence the wound depth was measured on the Stage 2 right buttock pressure injury. In addition, there was no documented evidence the patient’s education level was completed. On 8/8/23 at 0933 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 2's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 1/7/23. The patient was certified for home health services during the certification periods from 5/7/23 to 7/5/23 and 7/6/23 to 9/3/23. a. Review of the SOC OASIS dated 1/7/23, showed Patient 2 had hearing aids to both ears. Review of the Recertification OASIS dated 7/3/23, failed to show the patient's respiration rate, and capillary refill were assessed. In addition, patient was assessed to have no problems identified to the ears. On 8/8/23 at 0910 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding. #. Review of Patient 4's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/13/23. The patient was certified for home health services during the certification periods from 4/13/23 to 6 /11/23 and 6/12/23 to 8/10/23. Review of the Recertification OASIS dated 6/10/23, failed to show documentation of prior hospitalizations, and education level for Patient 4. On 8/8/23 at 0935 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding. 1. Review of Patient 1's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 2/7/22. The patient was certified for home health services during the certification period from 6/7/23 to 8/5/23. Review of the Recertification OASIS dated 6/5/23, revealed the SN documented a check mark showing the patient needed a PT referral. However, review of the clinical record showed no documented evidence the patient was evaluated and treated by the PT. Further review of the Recertification OASIS showed the SN documented the patient had her last bowel movement on 5/22/23, with a frequency of three to four times a day. However, there was no documented evidence showing the patient was experiencing constipation nor was there any documentation showing this was reported to the physician. On 8/8/23 at 0905 hours, an interview and concurrent clinical record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledge the finding. The Care Coordinator stated the patient did not have an order for a PT referral and that the SN documented this by mistake. The Care Coordinator also stated the SN documented the incorrect last bowel movement date.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was completed at discharge for two of seven sampled patients (Patients 6 and 7), creating the risk of not updating the patient's status for these patients.\ #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification periods from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. The Discharge OASIS dated 9/13/22, showed no documented evidence the patient’s oxygen saturation, the telephone number of the patient’s board and care, and the telephone number of the patient’s PCG/family member was completed. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 7's closed clinical record was initiated on 8/2/23. The clinical record showed the SOC was 3/15/23. The patient was certified for home health services during the certification periods from 3/15/23 to 5/13/23 and 5/14/23 to 7/12/23. The Discharge OASIS dated 5/31/23, showed no documented evidence the patient’s blood pressure, weight, temperature, pulse, respirations, oxygen saturation, prior history of hospitalizations, or a brief description of services were completed. On 8/8/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC was revised for one of seven sampled patients (Patient 5), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 5’s clinical record was initiated on 8/1/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification periods from 4/19/23 to 6/17/23, and 6/18/23 to 8/16/23. The PT Reassessment dated 6/16/23, showed PT visits 1W3 (one visit a week for three weeks) for therapeutic exercise, therapeutic activity, neuromuscular reeducation, gait training, and patient/PCG education. The POC, for the certification period from 6/18/23 to 8/16/23, showed SN visits 2W2 and 1W7. Review of the clinical record showed the PT had conducted the PT visits on 6/26 and 7/3/23. However, the POC for certification period from 6/18/23 to 8/16/23, failed to show documented evidence the POC was updated to include the PT visit frequency. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to coordinate the care to meet the patients' care needs for two of seven sampled patients (Patients 2 and 6), creating the risk of not providing the necessary care and services to these patients. #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification period from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. a. The Recertification OASIS dated 7/15/23, showed the bowel sounds were normal. Documentation showed the patient’s integumentary status was identified as dry. The SN note dated 7/26/23, showed the abdomen was soft and nondistended. Documentation showed the skin was intact. The SN note dated 8/1/23, showed the patient had diarrhea. Documentation showed the patient had mild redness on the bilateral groin area. Documentation showed the PCG reported patient had episode of loose BM. Documentation showed SN instructed the PCG/patient to drink plenty of water with electrolytes. Documentation showed to call the health provider if the diarrhea did not get better, diarrhea had bright red blood, dark colored poop with bloody streaks, fever of 100.4 degrees Fahrenheit or higher, painful or swollen abdomen and did not feel better after taking medication, fatigue, and vomiting. Documentation showed the PCG encouraged to keep patient's perineal area clean and dry to avoid skin irritation/skin break. However, there was no documented evidence the SN had coordinated with the physician regarding the patient’s diarrhea and mild redness on the bilateral groin area. b. The SN note dated 8/22/23, showed the patient had a left lower extremity discoloration. Documentation showed the staff did not know what happened. Documentation showed the patient denies pain or discomfort on the affected area. Documentation showed the staff reported the patient still gets up at night. Documentation showed the SN instructed the PCG that this is common for many dementia patients and poses a risk in several different ways. However, there was no documented evidence the SN had coordinated with the physician regarding the left lower extremity discoloration. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed of the finding. #. Review of Patient 2's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 1/7/23. The patient was certified for home health services during the certification period from 1/7/23 to 7/7/23. The Recertification OASIS dated 1/7/23, showed the patient had edema to right and left feet, good skin turgor, and no unhealed pressure injuries. The SN note dated 2/13, 2/21 and 2/26/23, showed the skin was intact, and the patient's left hand fifth finger was swollen and warm to touch. Documentation showed the PCG encouraged to increase patient's fluid intake and call health care provider if the patient have changes in condition. However, there was no documented evidence the SN had coordinated with the physician regarding the patient’s swollen fifth finger. On 8/8/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed of the finding.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to assess the patient or PCG’s competency related to wound care management for one of seven sampled patients (Patient 1). This failure created the risk for the patient not receiving the appropriate wound care which could lead to infections. Findings: Review of Patient 1's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 2/7/22. The patient was certified for home health services during the certification period from 6/7/23 to 8/5/23. The POC, for the certification period from 6/7/23 to 8/5/23, showed for the SN to assess, teach, and observe the competency of the patient/caregiver regarding the wound dressing changes. However, review of the clinical record showed no documented evidence showing the SN had assessed the patient/PCG’s competency related to wound care. On 8/8/23 at 0905 hours, an interview and concurrent clinical record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledge the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the visit schedules and treatments for two of seven sampled patients (Patients 3 and 4). This failure created the risk of not providing the necessary information to these patients. #. Review of Patient 4's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/13/23. The patient was certified for home health services during the certification period from 6/12/23 to 8/10/23. Review of the POC for the certification period of 6/12/23 to 8/10/23, cited SN visit frequency 1W9. On 8/2/23 at 0800 hours, a joint home visit was conducted with LVN 1 to Patient 4’s home. Review of the patient’s admission packet provided by the agency showed no documented evidence of the written instructions outlining the SN visit schedules. On 8/2/23 at 0835 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was asked to show the written instructions outlining the SN's visit schedules. LVN 1 verified there were no written instructions provided to Patient 4. 1. Review of Patient 3's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification period from 6/18/23 to 8/16/23. Review of the Therapy Order dated 7/24/23 cited PT visits 1W1 starting the week of 7/30/23. On 8/2/23 at 1445 hours, a joint home visit was conducted with PT 1 to Patient 3’s home. Review of the patient’s admission packet provided by the agency showed no documented evidence of the written instructions outlining the PT visit schedules. On 8/2/23 at 1512 hours, an interview and concurrent clinical record review was conducted with PT 1. PT 1 was asked to show the written instructions outlining the PT visit schedules. PT 1 verified she did not provide written instructions to the patients and only called the day prior to confirm the visit.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the treatments to be administered by the agency personnel for one of seven sampled patients (Patient 5). This failure created the risk of not providing the necessary information to this patient. Findings: Review of Patient 5’s clinical record was initiated on 8/1/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification periods from 4/19/23 to 6/17/23, and 6/18/23 to 8/16/23. Review of the POC, for the certification period from 6/18/23 to 8/16/23, showed SN to perform wound care on the right buttock pressure injury on each visit as follows: cleanse with normal saline, pat dry, cover with hydrocolloid (wound dressing), change dressing PRN if soiled. The physician’s order dated 6/18/23, showed SN visit 2W9 (two visits a week for nine weeks) to perform wound care on the left buttock pressure injury on each visit as follows: cleanse with normal saline, pat dry, cover with hydrocolloid dressing, change PRN if soiled. On 8/2/23 at 1400 hours, a joint home visit with the Care Coordinator was conducted to Patient 5's home. The Care Coordinator performed wound care to the patient’s right buttock pressure injury. The Clinical Coordinator stated the patient’s left buttock pressure injury was healed upon observation. Review of the patient’s home health folder showed no documented evidence of the written instruction outlining the treatment to be administered by the HHA personnel on the right buttock pressure injury. The Care Coordinator was informed of the findings. On 8/8/23 at 0933 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed of the findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement and maintain the infection control program including the surveillance, identification, prevention, and control, creating the risk of the spread of infections. Findings: Review of the infection control and QAPI documents was conducted on 8/7/23. 1. The agency failed to ensure the infection control data on the type of infection was analyzed and action plan/intervention was revised. For example: a. Review of the 2021 Second Quarter Infection Control Quarterly Report showed there were five cases of urinary infection. Review of the 2021 Third Quarter Infection Control Quarterly Report showed there were eight cases of urinary infection and one case of wound infection. Documentation showed the plan for the Second and Third Quarters Infection Control Quarterly Report included to continue to monitor the patient with possible risk of infection, continue to teach patient/PCG regarding important management of urine infection, keep hydrated, standard precaution/infection control measure; and continue to ensure all discipline were observing proper hand washing technique and standard precaution. The QAPI documentation for the second and third quarter of 2021 showed the intervention included the patient and PCG would be instructed on measures to avoid occurrence of UTI and SN would continue to observe proper hand washing/infection control measures. However, the agency failed to identify the increased number of urinary and wound infection from the second quarter to the third quarter. In addition, the plan/interventions had the same information for the second and third quarters in the Infection Control Quarterly Report and QAPI documents. b. Review of the 2022 First Quarter Infection Control Quarterly Report showed there were four cases of urinary infection and three cases of skin infection (total of seven cases of infection). Review of the 2022 Second Quarter Infection Control Quarterly Report showed there were five cases of urinary infection. The analysis for the 2022 Second Quarter Infection Control Quarterly Report showed all cases of infection were urinary infection. Documentation showed there was a decrease in number of patients with infection for this quarter. Documentation showed the patient with urinary infection was noted with urinary incontinence thus at risk for urinary infection. The analysis for the 2022 QAPI document showed one of the five cases of infection was from the SOC and four were developed during the certification period which were identified as "urinary." However, the agency failed to identify the increase of the urinary infection cases from the second to the third quarter of 2022. 2. The Quarter Infection Control Quarterly Report was not consistent with the QAPI documents. For example: Review of the 2021 Second Quarter Infection Control Quarterly Report showed there were five cases of urinary infection. The Second Quarter 2021 QAPI document showed there were four cases of infection for this quarter, and all were due to UTI. However, the number of cases of urinary infection in the 2021 Second Quarter Infection Control Quarterly Report was not consistent in the Second Quarter QAPI document. 3. The agency failed to ensure the individual Infection Control Report was completed. For example: a. Review of the Patient D’s individual Infection Control Report for the third quarter of 2021, showed the patient had urinary infection. However, the information related to the medication ordered, date started, and report date was blank. In addition, the documentation showed, “urinary tract infection” was listed as the signs and symptoms of infection. b. Review of Patient E’s individual Infection Control Report for the third quarter of 2021 showed the patient had skin infection. Documentation showed the patient was started on antibiotic for shingles. However, the information related to the medication ordered, date started, and report date was blank. c. Review of Patient F’s individual Infection Control Report for the third quarter of 2021, showed the patient had urinary infection. Documentation showed levofloxacin (antibiotic) and cephalexin (antibiotic) was ordered. However, the documentation showed, “urinary tract infection” was listed as the signs and symptoms of infection. On 8/8/23 at 0943 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed of the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the SN provided care and services in accordance with the POC for one of seven sampled patients (Patient 2), creating the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 2's clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/7/23. The patient was certified for home health services during the period from 5/7/23 to 7/5/23. The POC, for the certification period from 5/7/23 to 7/5/23, cited SN visits 1W9. The POC included SN to weigh the patient every visit or at least once a week and advise the patient and/or PCG to report for significant weight loss or gain. * However, the SN notes dated 5/10, 5/17, 5/27, 6/8, 6/13, and 6/21/23, showed no documented evidence the patient's weight was assessed during these visits. On 8/8/23 at 0906 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled staff prepared accurate and complete clinical notes for five of seven sampled patients (Patients 1, 2, 4, 6, and 7). This failure created the increased risk of substandard healthcare outcomes to these patients. #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification periods from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. a. The SN notes dated 5/23, 5/31, 6/9, 6/20, and 6/30/22, showed the patient had 0/10 pain (0=no pain and 10=worst pain). The Wound Note Worksheet dated 5/23, 5/31, 6/9, 6/20, and 6/30/22, showed the patient’s pain level was 1/10, wherein the pain level was inconsistent with the SN notes. b. The POC, during the certification periods from 7/20/22 to 9/17/22 showed the patient’s nutritional requirement was low salt and low fat/low cholesterol. The SN notes dated 7/26, 8/1, 8/8, 8/15, 8/22, 9/2, and 9/9/22, showed the patient’s diet was low salt, which was inconsistent with the POC. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 2's clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/7/23. The patient was certified for home health services during the certification period from 5/7/23 to 7/5/23. Review of the POC for the certification period from 5/7/23 to 7/5/23 showed the nutritional requirement as Puree with nectar thickened Liquid. Review of the SN Visit Notes dated 6/8, 6/13, 6/21/23, showed the patient's diet as low salt, which was inconsistent with the POC. On 8/8/23 at 0906 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the findings. #. Review of Patient 4's clinical record was initiated on 8/2/23. The clinical record showed the SOC was 4/13/22. The patient was certified for home health services during the certification periods from 4/13/23 to 6/11/23 and 6/12/23 to 8/10/23. a. Review of Patient 4's SOC OASIS dated 4/13/23, showed the patient had a hearing impairment to both ears and had highly impaired vision. Review of the SN notes dated 6/13, 6/20, 7/1. 7/5, and 7/13/ 23, showed sensory was WNL, which was inconsistent with the SOC OASIS assessment. b. Review of Patient 4's POC for the recertification period from 6/12/23 to 8/10/23, showed the Sn to continue to perform skilled nursing assessment observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications and exacerbation, knowledge and compliance to prescribed medications/ diet regimen, functional mobility, ability to self-care and home safety. Review of the SN notes dated 6/13/23 and 6/20/23, showed the patient was assessed to have a wound. However, further review of the clinical note failed to show a detailed description of the wound, notification to the physician, or if treatments were provided to the wound. c. Review of Patient 4's Recertification OASIS dated 6/10/23, showed under the section Genitourinary the patient was assessed with incontinence. Review of the SN visit notes dated 6/20, 7/1, 7/5, 7/13/23, showed under the section Genito-urinary as WNL. On 8/8/23 at 0935 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding. #. Review of Patient 7's closed clinical record was initiated on 8/2/23. The clinical record showed the SOC was 3/15/23. The patient was certified for home health services during the certification period from 3/15/23 to 5/13/23 and 5/14/23 to 7/12/23. Review of the physician order dated 5/1/23, showed ST recommended to rule out aspiration with recommended diet, improve safety with swallowing least restrictive diet by training caregivers. Review of the ST Evaluation Note dated 5/1/23, showed the patient's prior level of functioning was assessed WFLs with swallowing mechanical soft texts and regular liquids. In addition, the patient was cited to have a current diet texture of puree. Review of the SN Visit Notes dated 5/4, 5/13, 5/17, showed the patient's diet was low salt, which was inconsistent with the ST's recommended diet. Further review of the patient's closed clinical record failed to show a clarification of the patient's diet. On 8/8/23 at 0950hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the findings. Review of the agency’s P&P titled Clinical Data Collection Review dated 2009, showed the organization will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving service. 1a. Review of Patient 1's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 2/7/22. The patient was certified for home health services during the certification period from 6/7/23 to 8/5/23. Review of the Skilled Visit Notes during the certification period showed there were multiple dates where the SN documented the patient had edema. However, the SN did not specify the location and characteristics of the edema. For example, review of the Skilled Visit Notes dated 6/20/23, showed the SN documented a check mark showing the patient had a +1 pitting edema. However, there was no documented evidence showing the location of the edema. b. Review of the Skilled Visit Notes dated 6/20/23, showed the patient’s wound to the left lower leg was healed. However, further review of the Skilled Visit Notes after 6/20/23, showed the SN was still documenting the patient had a wound. For example, review of the Skilled Visit Notes dated 6/29/23 and 7/6/23 showed the SN documented the patient still had a wound. However, on 7/27/23, the SN documented the patient’s skin was intact. On 8/8/23 at 0905 hours, an interview and concurrent clinical record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledge the finding.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure CHHA 1 completed at least 12 hours of in-service training as required by the regulations. This failure created the risk of not providing the necessary care and services to the patients. Findings: Review of CHHA 1’s employee file was initiated on 8/7/23. CHHA 1 was hired on 1/1/22. Review of CHHA 1’s employee file showed the CHHA only completed a total of seven hours of in-service training in 2022. There was no documented evidence showing the CHHA completed the agency’s in-service trainings from January to May. On 8/8/23 at 0933 hours, an interview and concurrent documents review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledged the findings.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the CHHA followed the written assignment as prepared by the RN for two of seven sampled patients (Patients 2 and 7), creating the risk of not providing the necessary care and services to these patients. Findings 1. Review of Patient 2's clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/7/23. The patient was certified for home health services during the period from 5/7/23 to 7/5/23. The POC, for the certification period from 5/7/23 to 7/5/23, cited CHHA visits 2W9 to assist with bathing, assist with ADL care, and personal hygiene. Review of the Home Health Aide Visit dated 5/25/23, failed to show which tasks the CHHA had completed for this visit. On 8/8/23 at 1100 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 8/2/23. The clinical record showed the SOC was 3/15/23. The patient was certified for home health services during the period from 5/14/23 to 7/12/23. The POC, for the certification period from 5/14/23 to 7/12/23, cited CHHA visits 2W8. Review of the Home Health Aide Care Plan dated 5/14 and 5/24/23, failed to show Patient 7's bath frequency. Review of the Home Health Aide Visit dated 5/28/23, failed to show which tasks the CHHA had completed for the visit. On 8/8/23 at 1100 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the findings.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, the agency’s Governing Body failed to ensure overall management and operation responsibility related to Professional Advisory Committee meetings, creating the risk for not identifying potential problems, establishing, and implementing action plan. Findings: The agency’s P&P titled Professional Advisory Committee undated showed the Governing Body will appoint a multidisciplinary Professional Advisory Committee (PAC). The committee will consist of at least one practicing physician, a nurse with community or home health experience, and a representative of other professional services reflecting the scope of the organization services such as physical, speech or occupational therapy, social work, and discharge planning. At least one member of the committee is neither an Owners nor an employee of an organization. This committee will meet quarterly, or more as needed and minutes of each meeting will be recorded. The committee’s purpose is to assist the Executive Director/Administrator in an annual and ongoing review of the organization’s’ operation. The annual evaluation will be submitted to the GB for review and approval. The agency’s P&P titled Professional Advisory/Quality Management Committee dated 8/8/02 showed the membership shall include at least one representative from each of the following categories: licensed physician, RN, consumer, representative from each allied discipline utilized by the agency. The Professional advisory group shall organize at least annually and shall elect a chair, vice chair, and secretary. Regular meetings for the Professional advisory Group shall be held at least twice a year, to be held tentatively every April and October to advise the company on professional issues, participate in the evaluation of the company’s program, and assist the company in maintain liaison with other health care providers in a community information program. Review of the 2020, 2021, 2022, and 2023 QAPI documents showed the discussions were conducted quarterly regarding the fall incidents, hospitalization, infection control, record audit, and patients' complaints. Documentation showed the number/percentage of cases, goal, analysis, intervention, and responsible person. Review of the 2021, 2022, and 2023 Annual Program Evaluation and Professional Advisory Board Meeting showed the meeting were conducted on 3/18/21, 3/17/22, and 3/15/23, respectively. An interview was conducted with Administrator/DPCS on 8/7/23 at 0949 hours. She was asked to discuss about the infection control and QAPI program. She stated the gathering of infection control data were conducted by the Administrator/DPCS or the Care Coordinator every quarter. She stated the analysis of infection control data were performed by the Administrator/DPCS and Care Coordinator. She stated the information were reported to QAPI. She stated the QAPI members were composed of the Administrator/DPCS and Care Coordinator. She stated the QAPI meetings were held quarterly and would discuss about topics like infection control and hospitalization. She stated the PAC met once a year and discussed a brief review of what happened the past year such as QAPI, patient admissions, and budget. The PAC was composed of the Medical Director, CEO, DPCS, Care Coordinator, and each one of the following discipline PT, OT, ST, MSW, CHHA, and HR. However, the agency's PAC meetings held annually were not consistent with the agency’s P&P. On 8/8/23 at 0943 hours, an interview and concurrent documents record review was conducted with the Administrator/DPCS. She was informed of the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the responsibility for the day-to-day operations by not implementing the agency's P&P as evidenced by: * The agency failed to ensure the wounds were measured for depth and at least weekly as per the agency's P&P for three of seven sampled patients (Patients 1, 5, and 6). * The agency failed to ensure the written agreements for one of the two contractors (Contractor 1) included the required elements in the contracts as per Title 22. * The agency failed to show the current DPCS’s name and CDPH address in the patient handbook. These failures had the potential to negatively impact the agency’s operational performance. 3. Review of Patient 1's clinical record was initiated on 8/1/23. The clinical record showed the SOC was 2/7/22. The patient was certified for home health services during the certification period from 6/7/23 to 8/5/23. The POC, for the certification period from 6/7/23 to 8/5/23, showed to assess the patient’s wound to the left lower leg for signs and symptoms of infection/complication and to perform wound care on each visit until healed. Review of the Skilled Nursing Visit Notes during the certification period showed there were multiple dates where the patient’s wound was not measured weekly as per the P&P. For example, review of the Skilled Nursing Visit Notes dated 6/15/23 and 6/17/23, showed the wound dressing change was performed. However, there was no documented evidence showing the wound was measured. On 8/8/23 at 0905 hours, an interview and concurrent record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledged the findings. 4. According to Title 22 Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include the role, if any, of the agency and the contracted individual or agency in patient care conferences. Review of the written agreement between the agency and Contractor 1 providing therapy, nutrition, and social work services was initiated on 8/7/23. The written agreement did not include the role, if any, of the agency and the contracted individual or agency in patient care conferences. On 8/8/23 at 0926 hours, an interview and concurrent record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledged the findings. 5. Review of the Patient Handbook included in the admission packet provided to patients was initiated on 8/7/23. Review of the Patient Handbook did not show the current DPCS’s name. The Patient Handbook also showed the incorrect CDPH address. On 8/8/23 at 0926 hours, an interview and concurrent record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledged the findings. 6a. Review of the agency’s P&P titled Competency Assessment (undated) showed the competence of all organization staff (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year, when job responsibilities or duties change and during the annual performance evaluation. Review of the employee file for ST 1 was initiated on 8/7/23. ST 1 was hired on 8/30/21. Review of the employee file showed no documented evidence of ST 1’s skills competency for 2022. b. Review of the employee file for RN 1 was initiated on 8/7/23. RN 1 was hired on 10/8/20. Review of the employee file showed no documented evidence of RN 1’s skills competencies for 2021 and 2022. c. Review of the employee file for the Care Coordinator was initiated on 8/7/23. The Care Coordinator was hired on 3/27/06. Review of the employee file showed no documented evidence of the Care Coordinator’s skills competencies for 2020, 2021, 2022, and 2023. On 8/8/23 at 0933 hours, an interview and concurrent record review was conducted with the Care Coordinator. The Care Coordinator was informed and acknowledged the findings. The agency’s P&P titled Wound Assessment and Documentation dated 2002, showed inspect and evaluate the condition of the wound in the following manner: assess the wound location and its size, measure the length, width, and depth. Documentation guidelines included wound measurements (at least weekly), including the length, depth, and width. #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification periods from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. The physician’s order dated 5/23/22, showed cleanse left upper arm wound with normal saline, pat dry, apply Neosporin (topical antibiotic), cover with nonadherent dressing, secure with tape, and dressing changes daily. The Wound Note Worksheet dated 5/23/22, showed the patient’s left arm skin tear had a wound measurement of 2 cm (length) x 1 cm (width). The Wound Note Worksheet dated 5/31/22, showed the patient’s left arm skin tear had a wound measurement of 2 cm x 0.8 cm. The Wound Note Worksheet dated 6/9/22, showed the patient’s left arm skin tear had a wound measurement of 1.5 cm x 0.8 cm. The Wound Note Worksheet dated 6/18/22, showed the patient’s left arm skin tear had a wound measurement of 1.5 cm x 0.5 cm. The Wound Note Worksheet dated 6/20/22, showed the patient’s left arm skin tear had a wound measurement of 1.3 cm x 0.3 cm. The Wound Note Worksheet dated 6/30/22, showed the patient’s left arm skin tear had a wound measurement of 1 cm x 0.2 cm. However, there was no documented evidence the wound depth was measured. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on 8/1/23. The clinical record showed the SOC was 4/19/23. The patient was certified for home health services during the certification period from 4/19/23 to 6/17/23 and 6/18/23 to 8/16/23. Review of the POC, for the certification period from 6/18/23 to 8/16/23, showed SN to perform wound care on the right buttocks pressure injury on each visit as follows: cleanse with normal saline, pat dry, cover with hydrocolloid (wound dressing), change dressing PRN if soiled. The physician’s order dated 6/18/23, showed SN visits 2W9. The order showed SN to perform wound care on the left buttock pressure injury on each visit as follows: cleanse with normal saline, pat dry, cover with hydrocolloid dressing change PRN. The Wound Note Worksheet showed the patient’s Stage 2 pressure injury on the left and right buttock were measured for length and width during Week 1 (6/18/24 to 6/24/23), Week 2 (6/25 to 7/1/23), Week 3 (7/2/23 to 7/8/23) and Week 5 (7/16/23 to 7/22/23). However, there was no documented evidence the wound depth was measured for the Stage 2 left and right buttock. In addition, there was no documented evidence the patient’s Stage 2 pressure injury on the left and right buttocks were measured during Week 4 (7/9/23 to 7/15/23). On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge and transfer summaries were completed and sent to the the patients' physicians timely for two of seven sampled patients (Patients 6 and 7). This failure created the risk of providing substandard care to these patients. #. Review of Patient 7's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 3/15/23. The patient was certified for home health services during the certification period from 3/15/23 to 5/13/23 and 5/14/23 to 7/12/23. The Discharge OASIS dated 5/31/23, showed the patient was discharged on 5/31/23. The Discharge Summary dated 5/31/23, showed the physician was notified of discharge. Further review of the discharge summary failed to show the date of discharge or the last visit date. On 8/8/23 at 0950 hours, an interview and concurrent clinical record review was conducted with the Office Clerk. The Office Clerk was informed and acknowledged the finding. #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical record showed the SOC was 1/21/22. The patient was certified for home health services during the certification period from 5/21/22 to 7/19/22 and 7/20/22 to 9/17/22. The Discharge OASIS dated 9/13/22, showed the patient was discharged on 9/13/22. The Discharge Summary undated, showed the physician was notified of discharge. However, there was no documented evidence on the date the physician was notified of the discharge and the discharge summary was sent to the physician. In addition, there was no documented evidence the discharge summary included the medications the patient was on at the time of discharge. On 8/8/23 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding.