Every finding on record at His Grace Home Health Care LLC

Purpose of Visit: Recertification Survey and Follow-Up to Survey Conducted on 01/25/2019 Conducted entrance conference on 12/13/21 at 10:55 AM with administrator. Informed that the purpose of this visit was to conduct a recertification survey. Presented and discussed “What to Expect” letter. Provided list of requested documents and provided opportunity to ask questions. Entrance: 12/13/21 Exit: 12/15/21 Census: Licensed and Certified Home Health: 87 Licensed Home Health: 1 Personal Assistance Services: 0 Conducted exit conference on 12/15/21 at 11:47 AM with administrator. Presented and discussed preliminary findings. Provided “How to Write an Acceptable Plan of Correction” letter and provided opportunity to ask questions. Definitions: RN: Registered Nurse LVN: Licensed Vocational Nurse

Purpose of Visit: Recertification Survey and Follow-Up to Survey Conducted on 01/25/2019 Conducted entrance conference on 12/13/21 at 10:55 AM with administrator. Informed that the purpose of this visit was to conduct a recertification survey. Presented and discussed “What to Expect” letter. Provided list of requested documents and provided opportunity to ask questions. Entrance: 12/13/21 Exit: 12/15/21 Census: Licensed and Certified Home Health: 87 Licensed Home Health: 1 Personal Assistance Services: 0 Conducted exit conference on 12/15/21 at 11:47 AM with administrator. Presented and discussed preliminary findings. Provided “How to Write an Acceptable Plan of Correction” letter and provided opportunity to ask questions. Definitions: RN: Registered Nurse LVN: Licensed Vocational Nurse

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: THIS IS A CONTINUING DEFICIENCY Based on record review and interview, the agency Administrator failed to ensure the accurate and timely preparation of clinical notes for 7 of 7 active patient records reviewed (Patients #1, 2, 3, 4, 5, 6, and 7). This failure placed Patients #1, 2, 3, 4, 5, 6, and 7 at risk of not receiving appropriate care and services. The absence of clinical notes impeded the survey process and prevented the agency from performing a thorough Quality Assessment and Performance Improvement analysis. The absence of clinical notes also hampered coordination of care and created a barrier to accurate billing for services. The findings included: Patient #1: Review of plan of care (dated 11/30/2021-01/28/2022) revealed that Patient #1 was admitted on 02/03/21 with the primary diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia, with orders as follows, “SKILLED NURSING ONCE A WEEK X 9 WEEKS.” Review of records indicated that on 11/30/21, RN E was assigned to visit Patient #1 to perform nursing care. Review of Patient #1’s record revealed that no nursing note had been completed for 11/30/21. Review of records indicated that on 12/06/21, RN E was assigned to visit Patient #1 to perform nursing care. Review of Patient #1’s record revealed that no nursing note had been completed on 12/06/21. Patient #2 Review of plan of care (dated 9/12/21-11/29/21) indicated that on 5/15/21, Patient #2 was admitted to the agency for the care of a recurrent urinary tract infection (bladder infection), with orders for skilled nursing once a week for 9 weeks. Review of records indicated that on 11/19/21, RN F was assigned to visit Patient #2 to perform nursing care. Review of Patient #2’s record revealed that no nursing note had been completed for 11/19/21. Patient #3: Review of plan of care (dated 10/31/2021-12/29/2021) indicated that on 9/01/21 Patient #3 was admitted with the primary diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Skilled nursing was ordered once a week for 9 weeks. Review of records indicated that on 11/22/21, LVN G was assigned to visit Patient #3 to perform nursing care. Review of Patient #3’s record revealed that no nursing note had been completed for 11/22/21. Patient #4: Review of plan of care (dated 11/16/2021-01/14/2022) indicated that on 12/07/17, Patient #4 was admitted for wound care of a venous stasis ulcer of the left thigh. Skilled nursing was ordered once a week for one week, twice a week for 1 week, then once a week for 7 weeks, with 2 visits as needed. Review of records indicated that on 11/29/21, RN C was assigned to visit Patient #4 to perform nursing care. Review of Patient #4’s record revealed that no nursing note had been completed for 11/29/21. Review of records indicated that on 12/06/21, RN C was assigned to visit Patient #4 to perform nursing care. Review of Patient #4’s record revealed that no nursing note had been completed for 12/06/21. Patient #5: Review of plan of care (dated 9/17/21-1/06/22) indicated that on 11/08/21 Patient #5 was admitted to the agency for chronic kidney disease with heart failure. Skilled nursing was ordered twice a week for 1 week, then once a week for 8 weeks. Review of records indicated that on 11/15/21, the agency Administrator was assigned to visit Patient #5 to perform nursing care. Review of Patient #5’s record revealed that no nursing note had been completed for 11/15/21. Review of records indicated that on 11/22/21, the agency Administrator was assigned to visit Patient #5 to perform nursing care. Review of Patient #5’s record revealed that no nursing note had been completed for 11/22/21. Review of records indicated that on 11/29/21, the agency Administrator was assigned to visit Patient #5 to perform nursing care. Review of Patient #5’s record revealed that no nursing note had been completed for 11/29/21. Review of records indicated that on 12/06/21, the agency Administrator was assigned to visit Patient #5 to perform nursing care. Review of Patient #5’s record revealed that no nursing note had been completed for 12/06/21. Patient #6: Review of plan of care (dated 9/24/21-11/22/21) indicated that on 7/31/20, Patient #6 was admitted to the agency with the primary diagnosis of hypertension (high blood pressure). Skilled nursing was ordered once a week for 9 weeks. Review of records indicated that on 9/24/21, RN F was assigned to visit Patient #6 to perform nursing care. Review of Patient #6’s record revealed that no nursing note had been completed for 9/24/21. Review of records indicated that on 10/18/21, RN F was assigned to visit Patient #6 to perform nursing care. Review of Patient #6’s record revealed that no nursing note had been completed for 10/18/21. Review of records indicated that on 11/02/21, RN F was assigned to visit Patient #6 to perform nursing care. Review of Patient #6’s record revealed that no nursing note had been completed for 11/02/21. Patient #7: Review of plan of care (dated 10/17/21-12/15/21) indicated that on 10/17/21 Patient #7 was admitted for wound care of venous stasis ulcers of both ankles. Skilled nursing was ordered three times a week for one week, twice a week for 8 weeks, with two visits as needed. Review of records indicated that on 10/20/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 10/20/21. Review of records indicated that on 10/22/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 10/22/21. Review of records indicated that on 10/25/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 10/25/21. Review of records indicated that on 10/27/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 10/27/21. Review of records indicated that on 11/01/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/01/21. Review of records indicated that on 11/03/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/03/21. Review of records indicated that on 11/08/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/08/21. Review of records indicated that on 11/10/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/10/21. Review of records indicated that on 11/15/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/15/21. Review of records indicated that on 11/17/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/17/21. Review of records indicated that on 11/20/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/20/21. Review of records indicated that on 11/26/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/26/21. Review of records indicated that on 11/29/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 11/29/21. Review of records indicated that on 12/01/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 12/01/21. Review of records indicated that on 12/06/21, the agency Administrator was assigned to visit Patient #7 to perform nursing care. Review of Patient #7’s record revealed that no nursing note had been completed for 12/06/21. In an interview on 12/13/21 at 5:00 PM with Administrator, presented the finding that of 7 active patients reviewed, all 7 had multiple missing nurse notes. Administrator said, “We try to get the nurses to complete their charting, but it is hard to get them to do it. We are understaffed. We are trying to hire more nurses.” Review of agency policy dated (08/01/20) titled, “Timelines” read in part, “All agency staff… will be oriented to the following parameters… Daily progress notes with correlating time sheets are turned in within a maximum of seven (7) calendar days.”