Every finding on record at Home Sweet Home Ace Care LLC

Substantial Allegation Survey Substantial Allegation 106594 Partial Extended Survey The following deficiencies are based upon the substantial allegation survey #106594 completed on 05/29/24. Home Sweet Home Ace Care, 369162, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agency. An entrance conference was conducted on 05/28/24 at 10:21 AM with Human Resource person. An exit conference was conducted on 05/29/24 at 5:05 PM with administrative staff.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review, review of communication logs, review of scheduled visits, and staff interview, the agency failed to ensure OASIS assessments were completed upon a patient's transfer to a hospital. This affected three (Patient #1, Patient #2, and Patient #3) out of three patients reviewed. The agency census was 24. 1) Review of the electronic medical record for Patient #1 and a calendar of scheduled visits revealed Patient #1 was in the hospital from 10/19/23 through 11/01/23. No transfer OASIS was found after Patient #1 was admitted to the hospital. Interview on 05/28/24 at 12:58 PM the Administrator confirmed there were no transfer OASIS completed after Patient #1 was admitted to the hospital. 2) Review of an agency Patient Communication Log revealed on 01/20/24 the aide was informed by Patient #2 they were in the hospital for chest pain. Review of the medical record for Patient #2 did not reveal a transfer OASIS to the hospital. 3) Review of the agency schedule calendar revealed Patient #3 was admitted to the hospital on 03/18/24 to 03/22/24. Review of the medical record for Patient #3 did not reveal a transfer OASIS to the hospital. Interview on 05/29/24 at 4:10 PM the administrator confirmed there was no transfer OASIS completed when Patient #2 and Patient #3 were admitted to the hospital. 1. 2.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review, review of agency policy, and staff interview, the agency failed to ensure the patient was provided written notification of being discharged from services. This affected one (Patient #1) out of two discharged patients reviewed. The census was 24. Review of the medical record for Patient #1 revealed a start of care date of 06/23/24. Diagnosis included malignant neoplasm of the breast. Review of a Waiver Service Plan, effective 06/23/23 through 05/31/24, revealed personal care services 24 hours a week and nursing assessments every 60 days were ending on 02/25/24 due to change in service provider, increase in service, and termination of service. On 02/26/24 Patient #1 received services from a new provider. The record contained no written evidence Patient #1 was notified of being discharged from this agency. Review of the undated agency policy titled “Discharge Criteria,” revealed the patient is informed of discharge plan in a timely manner and acknowledges understanding of the reason. Interview on 05/28/24 at 1:28 PM, the Administrator confirmed there was no evidence Patient #1 had been notified of the impending discharge.

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 record review, policy review, and staff interview, the agency failed to ensure a medication profile was completed for each patient. This affected three (Patient #1, #2 and #3) out of three patients reviewed. The census was 24. 1) Review of the medical record for Patient #1 did not reveal a medication profile had been completed since the start of care dated 08/23/23. 2) Review of the medical record for Patient #2 did not reveal a medication profile had been completed since the start of care dated 10/13/23. 3) Review of the medical record for Patient #3 did not reveal a medication profile had been completed since the start of care dated 11/06/2019. Review of the undated agency policy titled “Initial assessment/Comprehensive Assessment” revealed each patient admitted will receive a comprehensive assessment. Each patient's comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, etc.) to identify side effects, drug interactions, noncompliance with medications, duplicate therapy, ineffective therapy, potential adverse effects, medication reactions, significant medication issues, omissions, dosage errors and management of oral and injectable medications. Interview on 05/29/24 at 3:26 PM the Director of Nursing confirmed a medication profile had not been completed since admission for Patient #1, Patient #2, and Patient #3.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to develop a plan of care for the necessary services for one (Patient #1) of three patients reviewed for plan of care. The census was 24. Review of the medical record for Patient #1 revealed a start of care date of 08/23/24. Diagnosis included malignant neoplasm of the breast. There was no care plan developed Review of a Waiver Service Plan, effective 06/23/23 through 05/31/24, revealed the HHA was to provide assistance with bathing, dressing, feeding, toileting, and assist with ambulation and transfers. Also assist with homemaking, meal prep, shopping, and medication reminder, for 24 hours per week, from 11/15/23 through 02/25/24. Interview on 05/28/24 at 12:00 PM the Administrator stated they "dropped the ball" and confirmed there was no plan of care for the services provided to the patient.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview, the agency failed to ensure there were physician orders for the services provided. This affected three (Patient #1, #2 and #3) out of three patients reviewed. The census was 24. 1) Review of the medical record for Patient #1 revealed start of care 08/23/23. There were no physician orders for services to be provided. The record and the staff time sheets revealed the home health aide (HHA) had completed visits on 09/06/23, 09/07/23, 09/10/23, 09/11/23, 09/17/23, 09/18/23 and 09/24/23. The HHA assisted with personal care, activities of daily living and light housekeeping. Review of the undated agency policy titled “Physician’s Orders – Verbal Orders” revealed drugs and treatments are administered by the agency staff only as ordered by the physician. Orders for patient care are obtained from the physician. Interview on 05/28/24 at 12:00 PM, the Administrator confirmed there were no physician physician orders for services provided to Patient #1 since start of care on 08/23/23. 2) Review of the medical record for Patient #2 revealed start of care on 10/13/23. Patient #2 used oxygen at 4 Liters per minute as needed. The skilled nurse was to go every 60 days to assess and evaluate Patient #2. A recertification comprehensive assessment was completed 01/08/24. The skilled nurse was to go every two months to assess and evaluate. There were no physician orders for the skilled nurse to visit every two months. Interview on 05/29/24 at 3:00 PM the Administrator confirmed there were no signed physician’s orders for the two skilled nurse visits that were made. 3) Review of the medical record for Patient #3 revealed start of care 11/06/2019. There were no physician’s orders. The medical record and time sheets found for the HHA revealed visits were made from 04/28/24 through 05/18/24. The HHA assisted with personal care, activities of daily living and light housekeeping. Interview on 05/29/24 at 4:30 PM the Administrator confirmed there were no physician orders found for services provided to Patient #3 since start of care on 11/06/2019.

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 policy review, record review, and staff interview, the agency failed to ensure the home health aide (HHA) had a plan of care written by the registered nurse (RN) to follow when providing services. This affected two (Patient #1 and #3) out of two patients reviewed with HHA visits. The census was 24. i Review of the medical record for Patient #1 did not reveal a care plan written by the RN for the HHA to follow. The medical record and time sheets for the HHA revealed visits on 09/06/23, 09/07/23, 09/10/23, 09/11/23, 09/17/23, 09/18/23 and 09/24/23 were made. Review of the medical record for Patient #3 did not reveal a care plan written by the RN for the HHA to follow. The medical record for Patient #3 and time sheets for the HHA revealed visits were made from 04/28/24 through 05/18/24. Review of the undated agency policy titled “Care Planning Process” revealed the patient care plan for the HHA will be developed by a RN (or a therapist or Speech Language Pathologist, if nursing not ordered) prior to Home Health Aide rendering care. This will be reviewed at least every 14 days during supervisory visit and based on patient's health status and environment. Interview on 05/29/24 at 2:58 PM the Administrator confirmed there were no plan of cares written by the RN for the HHA to follow for Patient #1 and Patient #3.

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 policy review, review of communication logs, record review, and staff interview, the agency failed to ensure a discharge summary was completed and sent to the physician at discharge. This affected two (Patient #1, Patient #2) out of three patients reviewed admitted to the hospital. The census was 24. f 1) Review of the medical record for Patient #1 revealed a start of care date of 08/23/24. Diagnosis included malignant neoplasm of the breast. Review of a Waiver Service Plan, dated 06/23/23 through 05/31/24, revealed personal care services 24 hours a week and nursing assessments every 60 days were ending on 02/25/24 due to change in service provider, increase in service, and termination of service. On 02/26/24 Patient #1 received services from a new provider. There was no evidence a discharge summary was completed and sent to the health care provider. Interview on 05/28/24 at 1:38PM the Director of Nursing (DON) confirmed there was no discharge summary completed and sent to the physician. 2) Review of an agency Patient Communication Log revealed on 02/19/24 Patient #2 was hospitalized, and the agency had not heard from the patient since that time, so Patient #2 was discharged. Further review revealed on 02/29/24 Patient #2 expired in the hospital. Review of the medical record for Patient #2 did not reveal a discharge summary. Interview on 05/29/24 at 4:10 PM the Administrator confirmed there was no discharge summary completed and sent to the physician. Review of the undated agency policy titled “Discharge Criteria,” revealed the patient is informed of discharge plan in a timely manner and acknowledges understanding reason. The Physician and other care providers will be informed and knowledgeable of discharge. Patients will receive verbal or written discharge Instructions. A complete list of reconciled medications will be provided to each patient on discharge. The list will be explained to patient/family and interaction documented.

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 02/17/21 Home Sweet Home Ace Care, is in compliance with the provisions of 42 CFR Part 484.102 for Home Health Agencies.

Partial Extended Recertification Survey COVID 19 Focused Infection Control Survey An entrance conference was held with the Director of Nurses on 02/09/21 at 10:15 A.M. and an exit conference was conducted with administrative staff on 02/17/21 at 1:30 P.M. The following deficiencies are based on the extended refortification survey completed on 02/17/21. Home Sweet Home Home Ace Care 369162, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 484.70 related to Infection Control.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to provide skilled nurse visits or home health aide services per the plan of care and failed notify the physician of missed skilled nursing and home health aide visits for four (Patients #2, Patient #3, Patient #4, and Patient #8) in a sample of ten patients. The agency census 22. Finding include: 1) Review of the medical record for Patient #2 revealed a start of care date of 01/19/21 and diagnoses which included: cirrhosis of the liver, end stage renal disease and diabetes mellitus. The Medicare certification period under review was 01/19/21 through 03/19/21. The plan of care directed the patient to have 20 hours of home health aide services for personal care and activities of daily living. Review of the documentation revealed Patient #2 incurred a hospitalization from 01/20/21 until 01/23/21. The agency documented the agency was notified of the patient's return to home on 01/25/21 and to resume service on 01/26/21. Review of the documentation revealed there were no home aide services provided the week of 01/25/21 after the patient's return and request to resume services. The week of 01/31/21 the home health aide completed 15 of the ordered 20 hours of home health aides services. Review of the medical record revealed patient had declined services on 01/20/21. Additionally, the agency failed to provide any home health aide services the week of 01/24/21 after services resumed on 01/26/21 following a hospitalization. The agency was unable to provide documentation the physician was notified of the missed visit. Interview with Staff A on 02/17/21 at 11:10 A.M., Staff A verbalized the agency was unaware the physician was to be notified of unskilled home health missed visits, the agency was only in the habit of notify the Medicaid case manager. Staff A verified the physician was not notified of the missed visits. 2) Review of the medical record for Patient #3 revealed the patient had a start of care date of 12/17/20. The patient was admitted to the agency with diagnoses which included: diabetes mellitus, hypertension, asthma, and arthritis. The Medicare certification period under review was 12/17/20 through 02/14/21. The plan of care directed the patient receive skilled nursing visits once per week for nine weeks. The medical record revealed the skilled nurse had made no weekly visits per the plan of care for the weeks of 12/20/20, 12/27/20, 01/03/21, 1/31/21, and 2/07/21. Review of the nursing documentation on 01/28/21 revealed the Licensed Practical Nurse (LPN) arrived at the patient's house for a visit and there was no answer at the door. The medical record lacked any documentation the physician was notified of the change in plan of care. Additionally, the skilled nurse made two visits, one on 01/13/21 and again on 01/15/21 to Patient #3 instead of the ordered once per week. Review of the agency skilled nursing visit documentation revealed the agency had failed to notify the physician of missed visits the week of 12/20/20, 12/27/20, 01/03/21, 01/17/21, and again on 01/24/21 Interview with Staff A on 02/17/21 at 10:43 A.M. confirmed the agency failed to notify the physician of missed visits for Patient #3 3) Review of the medical record for Patient #8 revealed a start of care with the agency on 03/30/20. The patient was admitted to the agency with diagnoses which included osteoarthritis. The Medicare certification period under review was 11/25/20 through 01/23/21. The plan of care directed the patient receive 14 hours per week of home health aide services for personal care and activities of daily living. Review of the Aide Visit Notes-Daily for the week of 12/13/20 the aide provided four hours of home health aide services from 5:00 P.M. until 9:00 P.M. on 12/14/20, 12/15/20, 12/16/20 and 12/17/20 for a total of 16 hours. The week of 12/20/20 the aide provided four hours of home health aide services from 5:00 P.M. until 9:00 P.M. on 12/21/20, 12/23/20, 12/24/20 and on 12/25/20 for total of 16 hours. The week of 12/27/20 the aide provided four hours of home health aide services from 5:00 P.M. until 9:00 P.M. on 12/28/20, 12/29/20, 12/30/20 and 12/31/20 for a total of 16 hours. 4) Review of the medical record for Patient #4 revealed the patient had a start of care dare of 01/24/20. The patient was admitted to the agency with diagnoses which included: acute myeloblastic leukemia, hypertension, anxiety, peptic ulcer and diabetes mellitus. The Medicare certification period under review was 01/18/21 through 03/18/21. The plan of care directed the patient receive home health aide services 14 hours per week for assistance with personal care and activities of daily living. Review of the medical record revealed Patient #4 notified the agency on 01/14/21 he would be out of town for a funeral. There was no evidence the physician was notified of the missed visit. Interview on 02/17/2021 at 11:10 A.M. Staff A verbalized the agency was notified the patient would be out of town for a funeral the from 01/18/21 through 01/22/21. Staff verbalized the agency was unaware the physician was to be notified of unskilled home health missed visits, the agency was only in the habit of notifying the Medicaid case manager. Review of the agency's hand written and undated policy directed that any changes in the plan of care or needs of patients were to be communicated to the patient's doctor or the staff on the case. These findings were confirmed in interview with Staff B on 02/17/21 at 10:43 A.M.

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 medical record review, responsibilities of the licensed practical nurse (LPN), and staff interview, the agency failed to ensure the skilled nurse (SN) provided the services as indicated in the plan of care for one (Patient #3) of one patient reviewed for skilled services in a sample of ten patients. The agency census was 22. Findings include: Review of the agency's job description and responsibilities for the LPN directed the LPN to perform care in accordance with the physician orders and the plan of care under the direction of the Registered Nurse (RN). The LPN was to observe signs and symptoms and report to the physician and the registered nurse reactions to treatments, including drugs, and changes in the patient's physical or emotional condition. Review of the medical record for Patient #3 revealed the patient had a start of care date of 12/17/20. The patient was admitted to the agency with diagnoses of diabetes mellitus, hypertension, asthma, and arthritis. The Medicare certification period under review was 12/17/20 through 02/14/21. The plan of care directed the patient receive skilled nursing visits once per week for nine weeks to include assessment of all body systems, vital signs, instruct and teach patient skin care, foot-care and prevention of skin breakdown, glucose monitoring and log keeping, medication compliance, and signs and symptoms of hypoglycemia and hyperglycemia. Review of the SN visit notes dated 01/13/21 and 01/15/21 revealed Staff B documented no vital signs during these visits. There was no documentation the SN educated the patient on skin care and examination of feet daily, blood sugar log keeping and what signs and symptoms to report to the physician. The SN visit note dated 01/13/21 documented the patient with a blood sugar of 364 (normal is 70-100 mg/dl). The nursing visit note failed to document the physician or the RN case manager was notified of this abnormally high blood sugar value. This deficient practice was confirmed during an interview with Staff A on 02/17/21 at 10:43 A.M.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on review of agency personnel file, agency policy and procedures review, and staff interview, the agency failed to evaluate one staff member (Staff G) of five staff reviewed for competency. This deficient practice had the potential to affect any patients Staff G provided care for. The census was 22. Findings include: Review of the agency's undated policy titled "Staff Competency Program" directed that each new employee would be evaluated for competency at the time of hire during orientation. Review of the personnel file of Staff G revealed a hire date of 10/19/18 as a home health aide. The agency was unable to provide documentation the staff member was skill and competency evaluated. Interview with Staff B on 02/17/21 at 10:43 A.M. confirmed this deficient practice.

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 personnel file review and agency staff interview, the agency failed to ensure home health aides completed 12 hours of annual in service education for three (Staff C, Staff D, and Staff G) of five personnel files reviewed for compliance. This had the potential to affect any patients provided care by these staff members. The agency census was 22. Findings include: Review of the personnel files of Staff C revealed the home health aide had a hire date of 01/19/18. The agency was unable to provide documentation the aide had completed the required 12 hours of annual in-service education in 2019. Review of the personnel files of Staff D revealed the home health aide had a hire date of 03/21/18. The agency was unable to provide documentation the aide had completed the required 12 hours of annual in-service education in 2019. Review of the personnel files of Staff G revealed the home health aide had a hire date of 10/29/18. The agency was unable to provide documentation the aide had completed the required 12 hours of annual in-service education in 2019. This deficient practice was confirmed during interview with Staff B on 02/17/21 at 10:43 A.M.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and agency policy and procedure review, the agency failed to ensure home health aides followed the plan of care. This deficient practice affected two patients (Patient #1 and Patient # 8) of ten medical records reviewed for aide compliance with the plan of care. The agency census was 22. Findings include: Review of the agency's undated policy and procedure titled, "Home Health Aide Documentation" directed the home health aide will document services rendered to the patient on the appropriate charting form. The aide will be responsible for reporting any changes in the patient's condition and/or other pertinent observations to the supervision Registered Nurse (RN) or therapist. 1) Review of the medical record for Patient #1 revealed the patient had a start of care dare of 05/02/20. The patient was admitted to the agency with diagnoses which included post traumatic first metacarpal joint osteoarthritis. The Medicare certification period under review was 12/25/20 through 02/25/21. The plan of care directed the patient to have 14 hours of home health aide services per week for personal care and activities of daily living. Review of the home health aide plan of care directed the aide to perform the following personal care duties for Patient #1 at each visit: hair care, skin care and dressing at each visit, encourage fluids, a light meal preparation, toileting and hygiene and a medication reminder, as well as weekly shower and hair shampoos. Review of the home health aide time sheets for 12/28/20 revealed the aide had failed to indicate whether the fluids had been encouraged, skin care provided, or a shower provided per the plan of care. The aide time sheets for 02/16/21 failed to document hair care, skin care, assistance with dressing, toileting and hygiene and encouragement of fluids were provided per the plan of care. 2) Review of the medical record for Patient #8 revealed a start of care with the agency on 03/30/20 with diagnoses which included osteoarthritis. The Medicare certification period under review was 11/25/20 through 01/23/21. The plan of care directed the patient receive 14 hours per week of home health aide services for personal care and activities of daily living. The home health aide plan of care directed the patient to have a shower, skin care, meal preparation and medication reminder at each visit and weekly shampoo and nail care Review of the Aide Visit Notes-Daily for the week of 12/14/20 revealed the aide failed to provide the weekly shampoo and nail care and the every visit shower and skin care as ordered for the entire week. The week of 12/20/2020 the aide failed to provide the ordered every visit meal preparation on 12/21/20 and 12/24/20. Additionally the home health failed to provide the every visit ordered skin care and shower for the entire week or the weekly shampoo and nail care for the week of 12/20/20 and week of 12/27/20. These findings were confirmed in interview with Staff B on 02/17/21 at 10:43 A.M.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on medical record review, agency policy and procedures review, and staff interview, the agency failed to conduct home health aide supervisory visits while the aide was on duty and performing care. This deficient practice affected one patient (Patient #7) of ten patients reviewed for timeliness of supervisory visits. The agency census was 22. Findings include: Review of the agency's undated policy titled, "Home Health Aide Supervision" directed if home health aide services were provided by the agency to a patient who was not receiving skilled care a Registered Nurse (RN) must make a supervisory visit to the patient's home no less frequently than every 60 days. Each of these supervisory visit must occur while the home health aide was providing care to the patient. Review of the medical record for Patient #7 revealed a start of care with the agency on 04/27/20 with diagnoses which included history of a cerebral vascular infarction (CVA). The Medicare certification period under review was 12/24/20 through 02/20/21. Review of the medical record revealed the home health aide provided aide service to Patient #7 Monday through Friday six hours per day. The RN completed the every 60 day re-certification visit and supervisory visit on Sunday 12/20/20 at 11:50 A.M. when the aide was off duty. This deficient practice was confirmed in an interview with Staff B on 02/17/21 at 10:43 A.M.