Every finding on record at I J Healthcare Nursing Resource Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/24/24. Standard level deficiencies cited. Abbreviations: AM = morning Pts. = Patients PM = afternoon/evening

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 a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to establish policies and procedures based on a risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan last updated on 12/23/23 was reviewed on 5/20/24. The Plan included multiple policies, procedures, and the Agency’s risk assessment form titled “Hazard Vulnerability Analysis (HVA): Agency (Facility-Based)”. The HVA form contained different types of potential emergencies associated with weather, utility failures, hazardous materials, security, terrorism, community mass casualty and other emergencies. The Agency was required to indicate the level of impact (low, moderate, or high) for the different types of emergencies, sign and date the form. The HVA form was left blank. The Agency failed to develop policies and procedures based on a completed risk assessment. 2. During an interview with the Administrator and Director of Nursing on 5/22/24 at 1:10 PM, both confirmed the above findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Plan as required. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan last updated on 12/23/23 was reviewed on 05/20/24. The Plan contained documentation that the Agency conducted table-top exercises in 2021, 2022, 2023, and on 01/14/24. 2. During an interview with the Administrator and Director of Nursing on 05/22/24 at 1:10 PM, the Director of Nursing confirmed that the Agency conducted only table-top exercises from 2021 to 2024. During the same interview, the Administrator and the Director of Nursing confirmed the Agency had not activated their Emergency Preparedness Plan since March 2020, and as of 5/22/24 the Agency did not participate in a full-scale or facility-based exercise from 2021 to 2024.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/24/24. Standard level deficiencies cited. Abbreviations: Pt. / Pts = Patient/Patients SOC = Start of Care # = number POC = Plan of Care A1C = glycosylated hemoglobin % = percent AM = morning PM = afternoon/evening GM = Gram (s) HCL= Hydrochloride RN = Registered Nurse mg = milligrams OASIS = Outcome Assessment Information Set PT = Physical Therapy

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 review of the Error Summary report and staff interview, it was determined that in 218 of 415 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 05/01/23 to 04/30/24 (12 months), was reviewed on 05/22/24. The report included a warning for 218 (52.53%) of 415 assessments with Error # -3330 Record submitted late, more than 30 days after completing the assessment. 2. During an interview with the Administrator and Director of Nursing on 05/23/24 at 9:45 AM, the Administrator stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrator confirmed the above findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined that in 2 of 7 (Pts. # 5 and 6) clinical records reviewed, the Agency failed to ensure that initial assessments were conducted within 48 hours of receiving the referral. Findings include: 1. Pt. #5 was admitted to Home Health Services on 10/30/23 with Diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/21/24. The SOC assessment dated 10/30/23, documented a referral date of 10/27/23, patient was not discharged from an inpatient facility, or did not have a physician ordered specific SOC date. The SOC assessment was conducted after 48 hours of the referral. 2. Pt. #6 was admitted to Home Health Services on 07/03/23 with Diagnosis of Primary Osteoarthritis. The clinical record was reviewed on 05/21/24 and 05/22/24. The SOC assessment dated 07/03/23, documented a referral date and inpatient discharged date of 06/26/23. The clinical record did not indicate a Physician ordered specific SOC date. The SOC assessment was conducted after 48 hours of the referral. 3. During interview with the Administrator and Director of Nursing on 05/23/24 at 9:45 AM, the Director of Nursing confirmed the above findings.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, it was determined that in 2 of 7 (Pts. #2 and 5) clinical records reviewed, the Agency failed to ensure the POC was updated to include Physician orders. Findings include: 1. Pt. #2 was admitted to Home Health Services on 11/09/23 with the primary diagnosis of Bilateral Primary Osteoarthritis of Knee. A home visit was conducted on 05/21/24 at 11:00 AM with Employee #6. During the home visit, the Pt. stated she was uncomfortable due to having “Shingles”. After the home visit an interview was conducted with Employee #6 that stated, the Agency did not inform him that the Pt. has Shingles. The clinical record was reviewed on 05/21/24 at 12:30 PM. The record contained the “Encounter Home Visit” form completed by the Physician Assistant on 04/29/24, signed by the Physician and faxed to the Agency on 05/13/24 which included, a new diagnosis of “Zoster with other complications”, and medications ”Ketoconazole (Topical) 2% apply 1 application to affected area 2 times per week for 4 weeks, Lidocaine HCI 3 % External Cream 3 times a day, Triamcinolone Acetonide (Topical) Apply 1 application topically to affected area daily for 4 weeks, Valacyclovir HCI 1 GM Take 1 tablet (1,000 mg) by mouth 3 times a day for 7 days”. As of 5/22/24, the POC effective 5/7/24 lacked an update to include the diagnosis and treatment of “Zoster with other complications”. 2. Pt. #5 was admitted to Home Health Services on 10/30/23 with primary diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/21/24. The Physician orders for recertifcation dated 2/23/24 and 04/25/24, indicated Agency to check A1C lab every 3 to 4 months. As of 05/23/24, the POC effective 02/27/24 to 04/26/24 and 04/27/24 to 06/25/24, lacked an update to include orders for Agency to check A1C lab every 3 to 4 months. 3. During interviews with the Administrator and Director of Nursing on 05/22/24 at 1:10 PM and on 05/23/24 at 9:45 AM, the Director of Nursing confirmed the above findings.

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 a review of clinical records and staff interviews, it was determined that in 3 of 7 (Pts. #2, 4 and 5) clinical records reviewed, the Agency failed to ensure staff provide treatment or service, as ordered by the Physician. Findings include: 1. Pt. #2 was admitted to Home Health Services on 11/09/23 with the primary diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 05/21/24. The record contained the RN visit note dated 04/25/24 which included, “…I instructed patient to take Melatonin 5mg at bedtime…” The POC for the certification period of 03/08/24 to 05/07/24 required Pt. #2 to take “Melatonin 3 mg-at bedtime”. 2. Pt. #4 was admitted to Home Health Services on 04/05/24 with the primary diagnosis of Stage 3 Pressure Ulcer of Left Hip. The clinical record was reviewed on 05/21/24. The record contained the Face to Face Encounter/Physician order form signed by the Physician, and forwarded to the Agency on 04/26/24. The order included: "Physical Therapy For: To evaluate and treat for functional deficits, related to mobility...Home safety evaluation. Strength, Gait, Balance training. Transfer training. Instruct on Fall prevention... Establish H.E.P (Home Exercise Program)..." As of 5/21/24, the record lacked documentation the Agency provided Physical Therapy on/or after 04/26/24. During an interview with the Administrator and Director of Nursing on 5/22/24 at 1:10 PM, both stated that the Agency has not referred Pt. #4 for a Physical Therapy evaluation. 3. Pt. #5 was admitted to Home Health Services on 10/30/23 with Diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/21/24. The Physician orders dated 2/23/24 and 04/25/24, indicated Agency to check A1C lab every 3 to 4 months. The clinical record included an A1C lab report dated 11/02/23. There were no modification of physician orders or communication as to why A1C lab was not done after 11/02/23. 4. During interviews with the Administrator and Director of Nursing on 05/22/24 at 1:10 PM and on 05/23/24 at 9:45 AM, the Director of Nursing confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on interview and observation during a home visit, clinical record review, Agency policy review, and staff interview, it was determined that in 1 of 7 (Pt. #2) clinical records reviewed, the Agency failed to inform staff for the need to use infection control practices in accordance with the Infection Prevention Standard of Practice, while providing service to a Pt. with an active infectious condition. Findings include: 1. Pt. #2 was admitted to Home Health Services on 11/09/23 with the primary diagnosis of Bilateral Primary Osteoarthritis of Knee. A home visit was conducted on 05/21/24 at 11:00 AM with Employee #6. During the home visit, an interview was conducted with the Pt. that stated she was uncomfortable due to having “Shingles”, observed Pt. #2 scratching her head and upper body. After the home visit an interview was conducted with Employee #6 that stated, the Agency did not inform him the Pt. has Shingles. The clinical record was reviewed on 05/21/24 at 12:30 PM. The record contained the “Encounter Home Visit” form signed by the Physician and faxed to the Agency on 05/13/24, the form included a new diagnosis of “Zoster with other complications”. The Agency failed to inform staff of the necessary precautions to prevent the spread of a viral infection. 2. The Agency's policy titled, "Communicable/Infectious Disease Information Table" was reviewed on 5/23/24 at 9:40 AM. The policy included: "Disease/Infection - Herpes Zoster (Shingles) localized disseminated... Mode of Transmission - Contact with moist lesions... Signs and Symptoms - Skin lesions". 3. During an interview with the Administrator and Director of Nursing on 5/22/24 at 1:10 PM, both confirmed the Agency failed to notify the RN and PT that Pt. #2 had an infectious condition. During an interview with the Director of Nursing on 5/23/24 at 9:20 AM, the Director of Nursing stated the Agency is required to notify staff of Pts. that have an infectious condition, so that staff may use correct precautions like gloves when in contact with the Pt., and to use dedicated equipment (blood pressure machine, thermometer, gait belt) to leave in the patient's home.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 1 of 2 (Pt. #6 ) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. 2. Pt. #3 was admitted to Home Health Services on 04/23/24 with the primary diagnosis of Other Seqelae of Cerebral Infarction. The clinical record was reviewed on 05/22/24. The record contained weekly Home Health Aide visit notes dated 05/03/24 and 05/06/24. As of 05/22/24, the record lacked documentation of any Home Health Aide supervision by the RN. 3. During interviews with the Administrator and Director of Nursing on 05/20/24 at 9:22 AM, the Director of Nursing stated only the RN conducts Home Health Aide supervision, and this is done every 14 days. During interviews with the Administrator and the Director of Nursing on 05/22/24 at 1:10 PM, and 05/23/24 at 9:45 AM, both confirmed the above findings. Findings include: 1. Pt. #6 was admitted to Home Health Services on 07/03/23 with primary diagnosis of Primary Osteoarthritis. The clinical record was reviewed on 05/21/24 and 05/22/24. The record contained Home Health Aide visit notes dated 07/24/24, 07/31/24 and 08/07/24. As of 05/22/24, the record lacked documentation of Home Health Aide supervision by the RN from 07/24/23 to 08/14/23.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan, Agency policy, and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on a facility-based and community-based risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. receiving services. Findings include: 1. The Agency's Emergency Preparedness Plan, last updated on 1/2/21, was reviewed on 5/18/21 at 9:40 AM. The plan contained a form titled "Hazard Vulnerability Analysis" which was blank. The plan lacked a facility based and community based risk assessment, using the all hazards approach for the years 2019 and 2020. 2. The Agency policy titled "Agency Facility-Based and Community-Based Risk Assessment" was reviewed on 5/18/21 at 9:50 AM. The policy required: "The Agency will perform a facility-based and community-based risk assessment utilizing an all hazard approach in order to develop an emergency plan...Hazard Vulnerability Analysis will be conducted and evaluated annually...planning for a full spectrum of emergencies or disasters (including internal emergencies and man-made emergencies or natural disasters) in the Agency's location, considering the particular types of hazards which may most likely occur in the Agency's area..." 3. During an interview with the Administrator and the Director of Nursing on 5/19/21 at 10:00 AM, the Administrator confirmed the Agency did not complete a Hazard Vulnerability Analysis for 2019 or 2020.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(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).] 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: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the plan contained volunteers. This has the potential to affect all Pts. receiving services. Findings include: 1. The Emergency Preparedness plan, last updated on 1/2/21, was reviewed on 5/18/21 at 9:40 AM. The Plan lacked any volunteers. 2. During an interview with the Administrator and the Director of Nursing on 5/19/21 at 10:00 AM, the Administrator confirmed the Agency's Emergency Plan lacked volunteers.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. receiving services. Findings include: 1. The Agency's Emergency Preparedness Plan, last updated on 1/2/21, was reviewed on 5/18/21 at 9:40 AM. The plan lacked any documentation that a full-scale community-based exercise, actual emergency, mock disaster drill, or table top exercise testing of its plan was performed for 2019 or 2020. 2. During an interview with the Administrator and the Director of Nursing on 5/19/21 at 10:00 AM, the Administrator confirmed the lack of testing of the Agency's emergency plan for 2019 and 2020.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 5/20/21. The Facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: POC = Plan of Care PsOC = Plans of Care Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon/Evening # = Number SOC = Start of Care POC = Plan of Care RN = Registered Nurse SN = Skilled Nurse PT = Physical Therapist/Physical Therapy SLP = Speech Language Pathologist W = Week mg/dl = milligrams per deciliter HGBA1C = Hemoglobin A1C MD/m.d. = Medical Doctor ABN = Advance Beneficiary Notice of Non-Coverage HHCCN = Home Health Change of Care Notice COVID-19 = Coronavirus 2019

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: . A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure Patient's medication profiles were reviewed by the RN during recertifcation comprehensive assessments. This was found in 6 of 7 (Pts. #1, 5, 7, 2, 3 and 4) clinical records reviewed. Findings include: 1. Pt. #1. SOC 1/27/21. Primary Diagnosis: Hemiplegia Following Cerebrovascular Disease Affecting Right Dominant Side. The clinical record was reviewed on 5/17/21 at 1:00 PM. The record contained a comprehensive recertification assessment, completed by the RN, and dated 3/26/21, for the recertification period beginning 3/28/21 to 5/26/21. The record also included a medication profile, which was last reviewed and signed by the RN on 1/27/21. The record lacked documentation the RN reviewed the Patient's medication profile upon recertifcation. 2. Pt. #5. SOC 1/8/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/18/21 at 11:20 AM. The record contained a comprehensive recertification assessment, completed by the RN, dated 3/5/21, for the recertification period beginning 3/9/21 to 5/721. The record also included a comprehensive recertification assessment dated 5/7/21, for the recertification period beginning 5/8/21 to 7/6/21. The record also contained a medication profile, which was last reviewed and signed by the RN on 1/8/21. The record lacked documentation the RN reviewed the Patient's medication profile upon either of the recertifcation assessments listed above. 3. Pt. #7. SOC 8/15/20. Primary Diagnosis: Hemiplegia Following Cerebrovascular Disease Affecting Left Non- Dominant Side. The clinical record was reviewed on 5/18/21 at 1:30 PM. The record a contained comprehensive recertification assessment, completed by the RN, dated 10/13/20, for the recertification period beginning 10/14/20 to 12/12/20. The record also included a comprehensive recertification assessment, completed by the RN, dated 12/11/20, for the recertification period beginning 12/13/20 to 2/10/21. The record also contained a medication profile, which was last reviewed and signed by the RN on 8/15/20. The record lacked documentation the RN reviewed the Patient's medication profile upon either of the recertifcation assessments listed above. 4. Pt. #2. SOC 1/15/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/17/21 at 3:30 PM. The record contained the recertification comprehensive assessment forms dated 3/12/21 and 5/12/21, indicating the RN updated the comprehensive assessment. As of 5/17/21, the record lacked documentation the RN reviewed the Medication Profile beyond the initial 60-Day certification period (1/15/21 to 3/15/21). 5. Pt. #3. SOC 12/23/20. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 5/18/21 at 12:45 PM. The record contained the recertification comprehensive assessment forms dated 2/17/21 and 4/21/21, indicating the RN updated the comprehensive assessment. As of 5/18/21, the record lacked documentation the RN reviewed the Medication Profile beyond the initial 60-Day certification period (12/23/20 to 2/20/21). 6. Pt. #4. SOC 3/2/21. Primary Diagnosis: Unspecified Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 5/18/21 at 2:15 PM. The record contained the recertification comprehensive assessment form dated 4/29/21, indicating the RN updated the comprehensive assessment. As of 5/18/21, the record lacked documentation the RN reviewed the Medication Profile beyond the initial 60-Day certification period (3/2/21 to 4/30/21). 7. The Agency's policy titled, "Initial Assessments/ Comprehensive Assessments" was reviewed on 5/19/21 at 9:45 AM. The policy required: "...7. Drug Regimen Review: Each patient's comprehensive assessment includes a review of all medications the patient is currently taking..." 8. During an interview with the Administrator and Director of Nursing on 5/19/21 from 10:00 AM to 11:42 AM, the Administrator and the Director of Nursing confirmed the Patient's medications are written on the "Medication Profile" form, and that the RN failed to review the patient's medications during the recertifcation comprehensive assessment.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure care was provided, as required by the Physician. This was found in 2 of 7 (Pts. #3 and 4) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/23/20. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 5/18/21 at 12:45 PM. The record contained the "Physician Telephone / Verbal Order" dated 12/23/20, 2/19/21 and 4/21/21 requiring: "Agency to Monitor HGBA1C Every 3 to 4 Months And Notify MD." The record contained HGBA1C results dated 11/13/20 and 5/6/21. The record lacked documentation the Agency monitored HGBA1C every 3 to 4 months. 2. Pt. #4. SOC 3/2/21. Primary Diagnosis: Unspecified Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 5/18/21 at 2:15 PM. The record included the SN visit note dated 4/9/21 which included the patient's "Blood Sugar: 387 mg/dl Random...MD Notification: Yes... Orders Received: Stated to recheck if still elevated call m.d. office..." The record lacked documentation the SN rechecked the patient's blood sugar, until the next weekly SN visit on 4/15/21. The POC effective 3/2/21 required: "...Assess cardiovascular... circulatory... for monitoring purposes and to notify the MD of significant findings..." The record contained the SN visit note dated 4/1/21 (Patient's weight: 203 pounds), the SN visit note dated 4/9/21 (Patient's weight: 212 pounds), the record lacked documentation the SN notified the MD of the 9 pound weight gain in 6 days. The record contained the SN visit note dated 4/23/21 (Patient's weight: 209 pounds), the SN visit note dated 4/29/21 (Patient's weight: 217 pounds), the record lacked documentation the SN notified the MD of the 8 pound weight gain in 6 days. 3. During an interview with the Administrator and Director of Nursing on 5/19/21 at 11:10 AM, the Director of Nursing stated: "The nurse is expected to notify the doctor or me, and I'll call the doctor" for a significant weight gain of 8 to 9 pounds within a week. During the same interview, the Administrator and Director of Nursing confirmed the Agency failed to ensure care was provided, as required by the Physician.

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: . A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to provide services as ordered in the POC. This was found in 2 of 3 Pts. (Pts. #1 and 5) for whom PT services were ordered by the Physician. Findings include: 1. Pt. #1. SOC 1/27/21. Primary Diagnosis: Hemiplegia Following Cerebrovascular Disease Affecting Right Dominant Side. The clinical record was reviewed on 5/17/21 at 1:00 PM. The record included the PsOC effective 1/27/21 to 3/27/21 and 3/28/21 to 5/26/21, which both included the Physician's order "PT 1W1 to evaluate." The record lacked documentation PT services were provided during this time period. The record also lacked documentation of a Physician's order to discontinue PT services. 2. Pt. #5 SOC 1/8/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/18/21 at 11:20 AM. The record included the POC effective 5/8/21 through 7/6/21. This POC included the Physician order "PT 1 WK 1." The record lacked documentation PT services were provided. The record also lacked documentation of a Physician's order to discontinue PT services. 3. The Agency policy titled "Initial Assessments/Comprehensive Assessments" was reviewed on 5/19/21 at 9:30 AM. The policy required: "...A RN, PT, or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the Patient's return home, or on the Physician-ordered start of care date..." 4. During an interview with the Administrator and Director of Nursing on 5/19/21 at 10:00 AM, the Administrator confirmed the above findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records, Agency policies and staff interview, it was determined the Agency failed to ensure that clinical documentation entered into the clinical record was complete and/or accurate. This was found in 7 of 7 (Pts. #2, 3, 4, 1, 5, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #2. SOC 1/15/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/17/21 at 3:30 PM. The record contained the form titled, "Beneficiary Elected Transfer" signed by the Pt. This form was left blank, lacking any other information (Date, patient's name, date of birth, Medicare #, effective date of transfer from previous Agency and the name of the previous Agency), as required by the Agency's form. The form titled, "Release of information authorization" was signed by the Pt. This form was left blank. The form lacked any other information (Patient's name, date of birth, name of hospital for inpatient stay), as required by the Agency's form. 2. Pt. #3. SOC 12/23/20. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 5/18/21 at 12:45 PM. The record contained the form titled, "Beneficiary Elected Transfer" signed by the Pt. This form was left blank and lacked any other information. The form titled, "Release of information authorization" was signed by the Pt. This form was left blank and lacked any other information. 3. Pt. #4. SOC 3/2/21. Primary Diagnosis: Unspecified Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 5/18/21 at 2:15 PM. The record contained the form titled, "Beneficiary Elected Transfer" signed by the Pt. This form was left blank and lacked any other information. The form titled, "Release of information authorization" was signed by the Pt. This form was left blank and lacked any other information. The form titled, "Patient's Choice Statement - Patient Transfer Statement" was signed by the Pt. and left blank. The form lacked any other information (Patient's name, name of Agency that previously provided care and/or service, and reason the Pt. transferred to this Agency), as required by the Agency's form. 4. Pt. #1. SOC 1/27/21. Primary Diagnosis: Hemiplegia Following Cerebrovascular Disease Affecting Right Dominant Side. The clinical record was reviewed on 5/17/21 at 1:00 PM. The record contained a form titled "Beneficiary Elected Transfer," which had sections for the Patient's name, date of birth, Medicare number, and name of previous Home Health Agency Pt. #1 was being transferred from. These sections were all left blank; however, the form was signed by Pt. #1 and dated 1/27/21. 5. Pt. #5. SOC 1/8/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/18/21 at 11:20 AM. The record contained a form titled "Beneficiary Elected Transfer," which had sections for the Patient's name, date of birth, Medicare number, and name of previous Home Health Agency Pt. #5 was being transferred from. These sections were all left blank; however, the form was signed by Pt. #5, with the date left blank. The form titled "Release of Information Authorization," which included sections for the Patient's name, date of birth, and name of hospital, were all left blank; however, the form was signed by Pt. #5. 6. Pt. #6. SOC 6/4/20. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/18/21 at 12:45 PM. The record contained a Physician's order dated 7/9/20 to discharge the Pt. from home health services. The record also included a form titled "Advance Beneficiary Notice of Non-Coverage," which contained sections including items/services, the reason Medicare will not pay for the items/services, the estimated cost of these items/services to the Pt., and whether or not the Pt. consents to receive the items/services. These sections were all left blank; however, the form was signed by Pt. #6 and dated 7/9/20, on the date Pt. #6 was discharged from the Agency. 7. Pt. #7. SOC 8/15/20. Primary Diagnosis: Hemiplegia Following Cerebrovascular Disease Affecting Left Non- Dominant Side. The clinical record was reviewed on 5/18/21 at 1:30 PM. The record contained a Physician's order dated 2/10/21 to discharge the Pt. from home health services. The form titled "Beneficiary Elected Transfer," which had sections for the Patient's name, date of birth, Medicare number, and name of previous Home Health Agency Pt. #7 was being transferred from, were all left blank; however, the form was signed by Pt. #7, and dated 8/14/20, which was the day before Pt. #7's admission to the Agency. The form titled "Release of Information Authorization," which included sections for the Patient's name, date of birth, and name of hospital, were all left blank; however, the form was signed by Pt. #7. The record also contained a form titled "Advance Beneficiary Notice of Non-Coverage," which contained sections including items/services, the reason Medicare will not pay for the items/services, the estimated cost of these items/services to the Pt., and whether or not the Pt. consents to receive the items/services, were were all left blank; however, the form was signed by Pt. #7 and dated 8/14/20, which was the day before Pt. #7's SOC with the Agency. The record also included a form titled "Home Health Change of Care Notice," which indicated the Pt. would not receive SN and PT services starting on 2/10/21, due to no further need for skilled services, was signed by Pt. #7, and dated 8/14/20, which was the day before Pt. #7's SOC with the Agency. The form titled "Notice of Medicare Non-Coverage," which indicated Pt. #7's current services from the Agency would end 2/10/21, was signed by Pt. #7 on 8/14/20, which was the day before Pt. #7'S SOC with the Agency. 8. The Agency policy titled "Home Health Change of Care Notice (HHCCN) and Advance Beneficiary Notice (ABN)" was reviewed on 5/18/21 at 3:00 PM. The policy required: "...Procedure for HHCCN: HHCCNs are issued to Patients receiving the home health care benefit for notification of changes....Once all blanks are completed and the form is signed, a copy is given to the Patient or Representative. In all cases, the Agency must retain the original notice on file..." 9. The Agency policy titled "Expedited Determination" was reviewed on 5/18/21 at 3:15 PM. The policy required: Each Medicare beneficiary will be notified in writing...no later than 2 days before covered homecare service(s) will end..." 10. The Agency policy titled "Release of Information" was reviewed on 5/18/21 at 3:25 PM. The policy required: "...Purpose: To guarantee that the Patient understands and consents to release of information..." 11. The Agency policy titled "Medical Record Entries and Authentication" was reviewed on 5/18/21 at 3:40 PM. The policy required: "All medical record entries will be dated..." 12. During an interview with the Administrator and the Director of Nursing on 5/19/21 from 10:00 AM to 11:42 AM, the Director of Nursing confirmed the above findings, and stated all documentation that is part of the clinical record should be complete and accurate.