Every finding on record at Inglewood Home Health Care, Inc.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure a comprehensive assessment OASIS (Outcome and Assessment Information Set, a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients) were completed at or after discharge, for the 15 of 19 sampled patients, (Patients 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and 35). This failure resulted to an incomplete documentation that accurately reflects the patients' current health status at discharge and the potential that patients’ discharge planning needs were not provided. On 7/18/23, at 10 a.m., a complaint validation survey revisit was conducted at the HHA (home health agency). During an interview with the Director of Patient Care Services (DPCS), the DPCS stated there were 15 active patients in their census. A review of the HHA's "Active Census" dated 7/18/23., indicated there were 15 active patients in the HHA roster list. During a review of the HHA's "Discharge List Of Patients", from dates 6/18/23 to 7/1/23, indicated the following findings: a. A review of Patient 21's Patient Information indicated a start of care (SOC) date of 7/24/23, with diagnosis that included chronic obstructive pulmonary disorder (COPD, a group of lung diseases that block airflow and make it difficult to breathe). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 21 was discharged on 6/21/23, due to goals were met. A further review of Patient 21's clinical record indicated that there was no discharge OASIS (Outcome and Assessment Information Set, a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients) done. b. A review of Patient 22's Patient Information indicated, a start of care (SOC) date of 1/12/23, with diagnosis that included diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 22 was discharged on 6/19/23, due to goals were met. A further review of Patient 22's clinical record indicated that there was no discharge OASIS done. c. A review of Patient 23's Patient Information indicated, a start of care (SOC) date of 5/4/23, with diagnosis of hypertension (a condition in which the force off the blood against the artery walls is too high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 23 was discharged on 6/27/23, due to goals were met. A further review of Patient 23's clinical record indicated that there was no discharge OASIS done. d. A review of Patient 24's Patient Information indicated, a start of care (SOC) date of 4/23/23, with diagnosis of lung cancer. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 24 was discharged on 6/21/23, due to goals were met. A further review of Patient 24's clinical record indicated that there was no discharge OASIS done. e. A review of Patient 25's Patient Information indicated, a start of care (SOC) date of 10/27/22, with diagnosis of heart failure (occur when the heart cannot pump or fill adequately). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 25 was discharged on 6/29/23, due to patient moved to another state. A further review of Patient 25's clinical record indicated that there was no discharge OASIS done. f. A review of Patient 26's Patient Information indicated, a start of care (SOC) date of 1/10/23, with diagnosis of diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 26 was discharged on 6/12/23, due to goals were met. A further review of Patient 26's clinical record indicated that there was no discharge OASIS done. g. A review of Patient 27's Patient Information indicated, a start of care (SOC) date of 5/6/23, with diagnosis of hypertension (a condition in which the force off the blood against the artery walls is too high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 27 was discharged on 6/30/23, due to goals were met. A further review of Patient 27's clinical record indicated that there was no discharge OASIS done. h. A review of Patient 28's Patient Information indicated, a start of care (SOC) date of 5/5/23, with diagnosis of hypertension (a condition in which the force off the blood against the artery walls is too high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 28 was discharged on 6/27/23, due to goals were met. A further review of Patient 28's clinical record indicated that there was no discharge OASIS done. i. A review of Patient 29's Patient Information indicated, a start of care (SOC) date of 1/23/23, with diagnosis of COPD (chronic obstructive pulmonary disorder - a group of lung diseases that block airflow and make it difficult to breathe). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 29 was discharged on 6/29/23, due to goals were met. A further review of Patient 29's clinical record indicated that there was no discharge OASIS done. j. A review of Patient 30's Patient Information indicated, a start of care (SOC) date of 6/2/23, with diagnosis of diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 30 was discharged on 6/30/23, due to change of insurance coverages. A further review of Patient 30's clinical record indicated that there was no discharge OASIS done. k. A review of Patient 31's Patient Information indicated, a start of care (SOC) date of 12/30/22, with diagnosis of fracture of fourth vertebrae. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 31 was discharged on 6/20/23, due to goals were met. A further review of Patient 31's clinical record indicated that there was no discharge OASIS done. l. A review of Patient 32's Patient Information indicated, a start of care (SOC) date of 4/27/23, with diagnosis of right shoulder pain. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 32 was discharged on 6/23/23, due to goals were met. A further review of Patient 32's clinical record indicated that there was no discharge OASIS done. m. A review of Patient 33's Patient Information indicated, a start of care (SOC) date of 5/2/23, with diagnosis of diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 33 was discharged on 6/30/23, due to goals were met. A further review of Patient 33's clinical record indicated that there was no discharge OASIS done. n. A review of Patient 34's Patient Information indicated, a start of care (SOC) date of 5/13/23, with diagnosis of pancreatic cancer. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 34 was discharged on 6/30/23, due to goals were met. A further review of Patient 34's clinical record indicated that there was no discharge OASIS done. o. A review of Patient 35's Patient Information indicated, a start of care (SOC) date of 1/23/23, with diagnosis of parkinson's disease (disorder of thee central nervous system that affects movement, often including tremors). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 35 was discharged on 6/29/23, due to goals were met. A further review of Patient 35's clinical record indicated that there was no discharge OASIS done. On 7/18/23, at 2 p.m., during an interview with the DPCS, she stated that the visiting nurse haven't submitted his discharge notes and completed the discharge oasis for Patients 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and 35 at this time. During a reference review at https://health.mo.gov/safety/homecare/OASIS/oasis-e-manual-final.pdf, Outcome and Assessment Information Set OASIS-E Manual, Effective January 1, 2023 Centers for Medicare and Medicaid Services, indicated the required timeframe of the comprehensive assessment after a discharge from an agency is within 2 calendar days of discharge date. A review of the HHA's undated policy and procedure, titled, "Discharge Criteria And Process", indicated an update to the comprehensive assessment, including required OASIS data elements will be completed, as required by regulation.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) discharge summary was completed at the time of discharge, for the 15 of 19 sampled patients, (Patients 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and 35). This failure resulted to an incomplete documentation that accurately reflects the patients' current health status at discharge and the potential that patients’ discharge planning needs were not identified and provided. On 7/18/23, at 10 a.m., a complaint validation survey revisit was conducted at the HHA (home health agency). During an interview with the Director of Patient Care Services (DPCS), the DPCS stated there were 15 active patients in their census. A review of the HHA's "Patient Census Report" dated 7/18/23, indicated there were 15 active patients in the HHA roster list. A review of the HHA's "Discharge List Of Patients", from dates 6/18/236 to 7/1/23, indicated the following findings: a. A review of Patient 21's Patient Information indicated, a start of care (SOC) date of 7/24/23, with diagnosis of chronic obstructive pulmonary disorder (COPD, a group of lung diseases that block airflow and make it difficult to breathe). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 21 was discharged on 6/21/23, due to goals were met. A further review of Patient 21's clinical record indicated that there was no discharge summary done. b. A review of Patient 22's Patient Information indicated, a start of care (SOC) date of 1/12/23, with diagnosis of diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 22 was discharged on 6/19/23, due to goals were met. A further review of Patient 22's clinical record indicated that there was no discharge summary done. c. A review of Patient 23's Patient Information indicated, a start of care (SOC) date of 5/4/23, with diagnosis of hypertension (a condition in which the force off the blood against the artery walls is too high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 23 was discharged on 6/27/23, due to goals were met. A further review of Patient 23's clinical record indicated that there was no discharge summary done. d. A review of Patient 24's Patient Information indicated, a start of care (SOC) date of 4/23/23, with diagnosis of lung cancer. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 24 was discharged on 6/21/23, due to goals were met. A further review of Patient 24's clinical record indicated that there was no discharge summary done. e. A review of Patient 25's Patient Information indicated, a start of care (SOC) date of 10/27/22, with diagnosis of heart failure (occur when the heart cannot pump or fill adequately). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 25 was discharged on 6/29/23, due to patient moved to another state. A further review of Patient 25's clinical record indicated that there was no discharge summary done. f. A review of Patient 26's Patient Information indicated, a start of care (SOC) date of 1/10/23, with diagnosis of diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 26 was discharged on 6/12/23, due to goals were met. A further review of Patient 26's clinical record indicated that there was no discharge summary done. g. A review of Patient 27's Patient Information indicated, a start of care (SOC) date of 5/6/23, with diagnosis of hypertension (a condition in which the force off the blood against the artery walls is too high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 27 was discharged on 6/30/23, due to goals were met. A further review of Patient 27's clinical record indicated that there was no discharge summary done. h. A review of Patient 28's Patient Information indicated, a start of care (SOC) date of 5/5/23, with diagnosis of hypertension (a condition in which the force off the blood against the artery walls is too high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 28 was discharged on 6/27/23, due to goals were met. A further review of Patient 28's clinical record indicated that there was no discharge summary done. i. A review of Patient 29's Patient Information indicated, a start of care (SOC) date of 1/23/23, with diagnosis of COPD (chronic obstructive pulmonary disorder - a group of lung diseases that block airflow and make it difficult to breathe). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 29 was discharged on 6/29/23, due to goals were met. A further review of Patient 29's clinical record indicated that there was no discharge summary done. j. A review of Patient 30's Patient Information indicated, a start of care (SOC) date of 6/2/23, with diagnosis of diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 30 was discharged on 6/30/23, due to change of insurance coverages. A further review of Patient 30's clinical record indicated that there was no discharge summary done. k. A review of Patient 31's Patient Information indicated, a start of care (SOC) date of 12/30/22, with diagnosis of fracture of fourth vertebrae. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 31 was discharged on 6/20/23, due to goals were met. A further review of Patient 31's clinical record indicated that there was no discharge summary done. l. A review of Patient 32's Patient Information indicated, a start of care (SOC) date of 4/27/23, with diagnosis of right shoulder pain. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 32 was discharged on 6/23/23, due to goals were met. A further review of Patient 32's clinical record indicated that there was no discharge summary done. m. A review of Patient 33's Patient Information indicated, a start of care (SOC) date of 5/2/23, with diagnosis of diabetes mellitus (a condition in which blood sugar is high). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 33 was discharged on 6/30/23, due to goals were met. A further review of Patient 33's clinical record indicated that there was no discharge summary done. n. A review of Patient 34's Patient Information indicated, a start of care (SOC) date of 5/13/23, with diagnosis of pancreatic cancer. On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 34 was discharged on 6/30/23, due to goals were met. A further review of Patient 34's clinical record indicated that there was no discharge summary done. o. A review of Patient 35's Patient Information indicated, a start of care (SOC) date of 1/23/23, with diagnosis of parkinson's disease (disorder of thee central nervous system that affects movement, often including tremors). On 7/18/23, at 11 a.m., during an interview with the DPCS, she stated Patient 35 was discharged on 6/29/23, due to goals were met. A further review of Patient 35's clinical record indicated that there was no discharge summary done. On 7/18/23, at 2 p.m., during an interview with the DPCS, the DPCS stated that the visiting nurse haven't submitted his discharge notes for Patients 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and 35 at this time. A review of the HHA's undated policy and procedure, titled, "Discharge Criteria and Process", indicated when the patient's plan of care changes and this change results in discharge from or reduction of services, a discharge summary will be completed and filed in the clinical record. A review of the HHA's document titled, "Provision of Care, Treatment and Service", revised November 2022, indicated a discharge summary will be completed for all discharged patients. A copy will be mailed to the physician. All discharge paperwork will be due in the office within 72 hours on the discharge date. This will include the discharge order, discharge summary and OASIS. The discharge record will be organized according to the organization policy regarding clinical record contents. Documentation will be reviewed by the Clinical Supervisor or designee and completed within 30 days of the discharge.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure plans for discharge were communicated to one of 19 sampled patients, (Patient 27). This failure resulted in violating the patient’s right to be involved in the discharge planning process and decisions prior to discharge. A review of Patient 27's Patient Information indicated, a start of care (SOC) date of 5/6/2023, with diagnosis of hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Patient 27's Home Health Certification and Plan of Care (POC) for the certification period starting from 5/6/2023 to 7/6/2023, included an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks, for SN (skilled nurse) to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, and medication knowledge and compliance. A review of the HHA's "Discharge List of Patients", from dates 6/18/2023 to 7/1/2023, indicated Patient 27 was included in the list. During an interview with the DPCS on 7/18/2023 at 11:00 a.m., the DPCS stated Patient 27 was discharged on 6/30/2023 due to goals were met. During a phone interview with Patient 27 and with the DPCS on 7/20/2023 at 2:00 p.m., when Patient 27 was asked if she was aware that she was already discharged from their home health services, she stated she was not aware of it. Patient 27 stated that the visiting nurse did not mention to her that the HHA was discharging her from their services during the last visit. A further review of Patient 27's clinical record indicated that there was no documented evidence of a discharge summary, discharge oasis, and physician's order for discharge was found in the chart. A review of the HHA's policy and procedure "Discharge Criteria and Process" revised in November 2022, indicated: When the patient's plan of care changes and this changes result in discharge from or reduction of services, the patient or his/her representative, as well as his/her primary physician (or other authorized licensed independent practitioner) will be notified and involved in planning decisions. The organization will verbally notify the patient of the decision to terminate or reduce services within one (1) visit prior to the time the change in service is occur (i.e., prior to the last scheduled visit). Prior notice will not be necessary when services are discontinued by the patient or physician; however, action taken must be documented in the clinical record and a discharge summary completed. The decision to terminate or reduce services must be documented in the clinical record, citing the circumstances and notifications to the patient, the responsible family/caregiver or representative, and the patient's physician. All discharge paperwork will be due in the office within 72 hours of the discharge date. this will include the discharge order, discharge summary, plan of care, medication profile, and OASIS (The Outcome and Assessment Information Set).

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: The HHA failed to ensure the patients Plan of Care (POC) was accurate and complete for one of six sampled patients (Patient 12). 1. The HHA failed to ensure to review and obtain from the physician, new order of insulin (a chemical messenger that allows cells to absorb glucose, sugar, from the blood) dose. The Director of Nursing Services (DPCS) did not obtain an order from the physician, on the new insulin dose identified from the patient's recent visit to the primary physician. This deficient practice had a potential for medication error that could place the patient at risk for reaction from incorrect insulin dose that includes hypoglycemia (a condition that occurs when the sugar levels (glucose) in the blood are too low, including sweating, headache, irregular heart beat) and hyperglycemia (condition characterized by high blood glucose (sugar) levels, including blurred vision, fatigue, lightheadedness. (Refer to G580). 2. The HHA failed to ensure the physician was notified promptly on the new identified insulin (hormone that lowers the level of glucose (a type of sugar) in the blood) order and coverage after the scheduled primary physician visit and update the patient plan of care (POC). This deficient practice placed the patient at risk for medication error and a potential for the patient receiving incorrect insulin dose. (Refer to G590). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services. .

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: The HHA failed to ensure to review and obtain from the physician, new order of insulin (a chemical messenger that allows cells to absorb glucose, sugar, from the blood) dose. The Director of Nursing Services (DPCS) did not obtain an order from the physician, on the new insulin dose from the patient recent visit to the physician. This deficient practice had a potential for medication error that could place the patient at risk for reaction from incorrect insulin dose that includes hypoglycemia (a condition that occurs when the sugar levels (glucose) in the blood are too low, including sweating, headache, irregular heart beat) and hyperglycemia (condition characterized by high blood glucose (sugar) levels, including blurred vision, fatigue, lightheadedness) . A review of Patient 12's "Patient Information" indicated a start of care date (SOC) of 12/10/22, with diagnoses which included diabetes mellitus (high sugar level in blood). A review of Patient 12's Home Health Certification and Plan of Care (POC) for the certification period starting from 2/8/23 to 4/8/23, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, for SN (skilled nurse) to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). A physician's order included in the POC have the following prescribed medications: a. Novolog (a rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes) 100 unit/ml injectable solution administered subcutaneous (the injection is given in the fatty tissue, just under the skin), to inject 12 units subcutaneously three times daily before meals. b. Basaglar (a long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours) 100 unit/ml in 3 ml pen injector, to inject 35 units subcutaneous once a day. c. Trulicity (an injectable diabetes medicine that helps control blood sugar levels) 3 mg in 0.5 ml auto-injector, to administer 3 mg subcutaneously once a week on Monday. On 6/7/23, at 11 a.m., a joint home visit was conducted at Patient 12's residence with Director of Patient Care Services (DPCS) Patient 12 was observed sitting up in a chair, alert and oriented, and was ambulating with steady gait. During a review of Patient 12's medications indicated there were one insulin injector pen labeled Novolog 100 unit/ml, to inject 12 units subcutaneously three times daily before meals, one insulin injector pen labeled Basaglar 100 unit/ml in 3 ml, to inject 35 units subcutaneously once a day and one insulin injector pen labeled Trulicity 3 mg in 0.5 ml, to administer 3 mg subcutaneously once a week on Monday. On 6/7/23, at 11:30 a.m., during an interview Patient Caregiver 2 (PCG 2) stated, she prepare and administered the patient's medications daily as scheduled, check the patient's blood sugar every morning and at night. PCG 2 further stated that she administers Novolog 10 units insulin before breakfast and dinner and Novolog 12 units before eating lunch (while the order was Novolog 12 unit three times a day, a total of 4 unit less from the order), Basaglar insulin 20 units before breakfast and dinner daily (while the order was Basaglar insulin 35 units once a day, a total of 5 units more from the order and to be given 2 times a day and previous order once a day) and Trulicity insulin 3 mg every Monday for Patient 12. PCG 2 stated, Patient 12 went for a routine physician visit on 5/30/23 and gave the new order for Novolog and Basaglar insulin orders. The patient's physician visit was a day before the scheduled HHA skilled nurse home visit. On 6/8/23, at 11 a.m., a review of Patient 12's medical records indicated there was no physician's order for the Novolog and Basaglar new insulin dosage coverage and the HHA SN visit did not assess and review the patient medications after the patient's scheduled physician visit. On 6/8/23, at 11:10 a.m., during an interview the DPCS stated, the HHA did not followed-up with the physician and obtain orders for this new Novolog and Basaglar insulin dose.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: The HHA failed to ensure the physician was notified promptly on the new identified insulin (hormone that lowers the level of glucose (a type of sugar) in the blood) order and coverage after the scheduled primary physician visit and updated the patient's plan of care (POC). This deficient practice placed the patient at risk for medication error and a potential for the patient receiving incorrect insulin dose. A review of Patient 12's "Patient Information" indicated a start of care date (SOC) of 12/10/22, with diagnoses which included diabetes mellitus (high sugar level in blood). A review of Patient 12's Home Health Certification and Plan of Care (POC) for the certification period starting from 2/8/23 to 4/8/23, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, for SN (skilled nurse) to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). A physician's order included in the POC have the following prescribed medications: a. Novolog 100 unit/ml injectable solution administered subcutaneously, to inject 12 units subcutaneously three times daily before meals. b. Basaglar 100 unit/ml in 3 ml pen injector, to inject 35 units subcutaneously once a day. c. Trulicity 3 mg in 0.5 ml auto-injector, to administer 3 mg subcutaneously once a week on Monday. On 6/7/23, at 11 a.m., a joint home visit was conducted at Patient 12's residence with DPCS. Patient 12 was observed sitting up in chair, alert and oriented, and ambulating with steady gait. During a review of Patient 12's medications indicated there were one insulin injector pen labeled Novolog 100 unit/ml, to inject 12 units subcutaneously three times daily before meals, one insulin injector pen labeled Basaglar 100 unit/ml in 3 ml, to inject 35 units subcutaneously once a day and one insulin injector pen labeled Trulicity 3 mg in 0.5 ml, to administer 3 mg subcutaneously once a week on Monday. On 6/7/23, at 11:30 a.m., during an interview PCG 2, stated she prepare and administered the patient's medications daily as scheduled, check the patient's blood sugar every morning and at night. PCG 2 further stated that she administered Novolog 10 units insulin before breakfast and dinner, Novolog 12 units before eating lunch (while the order was Novolog 12 unit three times a day, a total of 4 unit less from the order). Basaglar insulin 20 units before breakfast and dinner daily (while the order was Basaglar insulin 35 units once a day, a total of 5 units more from the order and to be given 2 times a day and previous order once a day). Trulicity insulin 3 mg every Monday for Patient 12. PCG 2 stated, Patient 12 went for a scheduled primary physician visit on 5/30/23 and gave the new order for Novolog and Basaglar insulin orders. The patient's scheduled primary physician visit was a day before the scheduled HHA skilled nurse home visit. On 6/8/23, at 11 a.m., a review of Patient 12's medical records indicated there was no physician's order for the Novolog and Basaglar new insulin dosage coverage and the HHA SN visit did not assess and review the patient medications after the patient's scheduled physician visit. On 6/8/23, at 11:10 a.m., during an interview the DPCS stated, there did not follow-up with the physician and obtain orders for the new Novolog and Basaglar insulin coverage. A review of the agency's undated policy and procedure of "Plan of Care" indicated it is the staff member's responsibility to report any condition or problems to the physician.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health agency (HHA) failed to coordinate with the patient primary physician on the patient's diabetic care and needs for one of six patients (Patient 12). The visiting nurse failed to coordinate with Patient 12 regarding her MD appointment and was not aware of patient's new insulin coverage orders. This deficient practice placed the patient at risk for hypo/hyperglycemia crisis. A review of Patient 12's "Patient Information" indicated a start of care date (SOC) of 12/10/22, with diagnoses which included diabetes mellitus (high sugar level in blood). A review of Patient 12's Home Health Certification and Plan of Care (POC) for the certification period starting from 2/8/23 to 4/8/23, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, for SN (skilled nurse) to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). A physician's order included in the POC have the following prescribed medications: a. Novolog 100 unit/ml injectable solution administered subcutaneously, to inject 12 units subcutaneously three times daily before meals. b. Basaglar 100 unit/ml in 3 ml pen injector, to inject 35 units subcutaneously once a day. c. Trulicity 3 mg in 0.5 ml auto-injector, to administer 3 mg subcutaneously once a week on Monday. On 6/7/23, at 11 a.m., a joint home visit was conducted at Patient 12's residence with DPCS (director of patient care services). Patient 12 was observed sitting up in chair, alert and oriented, and ambulating with steady gait. During a review of Patient 12's medications indicated there were one insulin injector pen labeled Novolog 100 unit/ml, to inject 12 units subcutaneously three times daily before meals, one insulin injector pen labeled Basaglar 100 unit/ml in 3 ml, to inject 35 units subcutaneously once a day and one insulin injector pen labeled Trulicity 3 mg in 0.5 ml, to administer 3 mg subcutaneously once a week on Monday. On 6/7/23, at 11:30 a.m., during an interview with PCG 2 stated, she prepares and administers the patient's medications daily as scheduled, check the patient's blood sugar every morning and at night. PCG 2 further stated that she administers Novolog 10 units insulin before breakfast and dinner, Novolog 12 units before eating lunch, Basaglar insulin 20 units before breakfast and dinner daily and Trulicity insulin 3 mg every Monday for Patient 12. She also stated that Patient 12's physician gave this new Novolog and Basaglar insulin orders when the patient went to her MD appointment on 5/30/23. On 6/8/23, at 11:10 a.m., during an interview with the DPCS (director of patient care services), she stated she was not aware there was a new insulin coverage order for Novolog and Basaglar insulin for Patient 12. She also stated that she could not find a communication note from the visiting nurse stating that the patient will have an MD appointment on 5/30/23. She further stated that the visiting nurse should always coordinate with the patient/caregiver to know if there is an upcoming MD appointment or a scheduled visit to the hospital during her visits. A review of the agency's undated policy and procedure titled, "Position Descriptions, RN Case Manager," indicated... Responsibilities (Case Managing & Supervising): Reports to the Director of Patient Care Services, other professional personnel, and physician (when appropriate) any changes in patient's signs/symptoms, physical status or major changes in care plan or referral to other services, Supervises and Communicates to all members of the care team to improve the quality and condition of patient care, thereby assisting in the coordination of all services provided.

The following reflects the findings of the California Department of Public Health during a Recertification Survey, from 5/2/23 to 5/4/23, at this location: 14015 Van Ness Avenue, 6700 Fallbrook Avenue, Suite 7, Gardena, CA 90249. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID #22303 Health Facilities Evaluator Nurse, Surveyor ID #44186 Unduplicated admissions: 336 Active patients: 102 Sample Size: 10 Home Visits: 5 The following Conditions of Participation not met: 484.55 Comprehensive Assessment of Patients

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to assess the patient for continuing need for home care services for six of 10 sampled patients (Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9). (Refer to G532). 2. The HHA failed to update the medication profile (the information about the medication a person is using and has used) that reflect the patients' current medications for two of 10 sampled patients (Patient 1 and Patient 2). (Refer to G536) The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment. .

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for skilled nursing services for six of 10 sampled patients (Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9). This deficient practice resulted in the provision of an unnecessary home health services to the patients who did not need skilled nursing services. Findings: a. A review of Patient 2's clinical record indicated a start of care date (SOC) of 2/22/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal disease (when the kidneys are no longer able to function normally), and dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to). A review of Patient 2's Home Health Certification and Plan of Care (POC) for the certification period starting from 2/17/2023 to 4/17/2023, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, to assess all body systems, vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level, severe shortness of breath, blood sugar check(measures the level of glucose in your blood), medication and diet compliance, and safety on every visit. The goal included patient’s blood sugar will be maintained within the range 60-250 milligrams per deciliter (mg/dl), patient will have no skin breakdown, blood pressure levels maintained within normal parameters, no signs and symptoms of shortness of breath and respiratory distress, and patient will remain safe at home without incidents of fall, injury or hospitalization throughout the certification period. Discharge planning indicated to discharge when medical condition is stable, and when patient is no longer in need of skilled services. On 5/03/2023, at 11:55 a.m., a joint home visit was conducted at Patient 2's residence with the DPCS Designee (DPCSD). Patient 2 was observed sitting up in chair, alert and oriented, and ambulatory using a cane, accompanied by the patient’s caregiver (PCG 1). On 5/03/2023 at 12:15 p.m., during an interview with Patient 2, he stated he takes his medications daily as scheduled, check his blood sugar every morning, give himself insulin injection (is used to treat high blood glucose) at night, have no wounds, no falls, and no hospitalization for the past 12 months. Patient 2 also stated he has no pain and goes visit his physician regularly. A review of Patient 2's SN Visit Notes from 2/20/2023 to 4/06/2023 indicated Patient 2’s blood sugar ranging from 115 to 137, blood pressure ranging from 132-145 systolic (first number) and 65-88 diastolic (second number). The rest of the patient's vital signs (temperature, pulse rate and respiratory rate) were within a normal range. There were no admissions to the hospital, no pain, no episodes of falls, no wound care performed, and any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. On 5/03/2023 at 3:40 p.m., during an interview with the Patient 2’s physician (NP 1), she stated Patient 2 have no recent hospitalization, no falls, no wound care, no rehabilitation services, and should have been discharged. b. A review of Patient 3's clinical record indicated a start of care date (SOC) of 10/13/2022, with diagnoses which included essential hypertension (high blood pressure), dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning), and anemia (a condition in which the body lacks enough healthy red blood cells to carry adequate oxygen to your body's tissues). A review of Patient 2's Home Health Certification and POC for the certification period starting from 2/10/2023 to 4/10/2023, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, to assess all body systems, vital signs, pain level, severe shortness of breath, medication and diet compliance, and safety on every visit. The POC indicated to notify the physician if blood pressure (Bp) is below 90/50 or above 160/90, heart rate is below 50 or above 100 bpm, and pain greater than 5 on a pain scale 0-10 (0: no pain, 10: unbearable pain). The goal included patient’s general health condition will remain stable as observed, blood pressure levels maintained within normal parameters, musculoskeletal status will improve as evidenced by increase in strength, endurance and mobility, decreased pain to a tolerable level of 1-2/10, and patient will remain safe at home without incidents of fall, injury or hospitalization throughout the certification period. Discharge planning indicated to discharge when medical condition is stable, and when patient is no longer in need of skilled services. On 5/03/2023 at 4:10 p.m., during a phone interview with the Patient 3’s family member (FM 2), she stated Patient 3’s blood pressure had been well-controlled for the most part with medications, can walked around the house independently, have no recent hospitalization, no falls, and no wound care. A review of Patient 3's SN Visit Notes from 2/16/2023 to 4/11/2023 indicated Patient 3’s blood pressure ranging from 118-130 systolic and 72-82 diastolic. The rest of the patient's vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, pain level at a tolerable level of 2/10, no wound care performed, and any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. On 5/04/2023 at 12:15 p.m., during an interview with the Director of Patient Care Services Designee (DPCS Designee), he stated Patient 2 and Patient 3’s vital signs have been stable, no change in condition of the patient, no falls, no hospitalization, no wound care done, patient goals have been met and should have been discharged. A review of the agency’s policy and procedure titled, "Discharge Criteria and Process", revised November 2022, indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician (or other authorized licensed independent practitioner) and the organization agree that the goals of home health have been attained or are no longer attainable. c. A review of Patient 6's clinical record indicated a start of care date (SOC) of 11/4/22, with diagnoses which included essential hypertension (high blood pressure). A review of Patient 6's Home Health Certification and Plan of Care (POC) for the certification period starting from 11/4/22 to 1/3/23, included an order for the skilled nurse (SN) to visit Patient 6 once a week for nine weeks, to observe and reassess: Homebound status, cardiovascular status, endocrine status, and hydration/nutrition status. Medication compliance and perform vital signs check. The POC indicated to notify the physician if Patient 6's blood pressure (BP) is below 90/60 or above 155/90, or if heart rate is below 50 beats per minute (bpm) or above 100 bpm, and pain is above seven on a pain scale of 1-10 (0: no pain, 10: unbearable pain). The listed goal indicated Patient 6 will do the following: Demonstrate compliance with medications. Maintain BP in range of 120-150/60-90 mm Hg. Demonstrate home safety measures. Skin integrity will be maintained without any form of infection or skin breakdown. Discharge planning indicated to discharge when goals are met, when patient no longer in need of skilled services, and when patient reaches maximum functional potential. On 5/3/23, at 11 a.m., a home visit was conducted to Patient 6's residence with LVN 1. Patient 6 was observed alert, oriented and ambulatory using a cane. On 5/3/23 at 11:20 a.m., during an interview with Patient 6's primary caregiver (son), he stated that he prepares the patient's medications and administer to her regularly, monitors her blood sugar daily, and takes her to her physician every couple of months. He also stated that Patient 6 does not have any body ache, headache or pain, no falls, no hospitalization, and does her activities of daily living (ADLs, like bathing, toileting, dressing, eating, mobility) independently and/or with assistance by himself. A review of Patient 6's Clinical Nursing Notes from 11/4/23 to 1/3/23 indicated Patient 6’s blood pressure ranged from 133-141 systolic (top number) and 74-84 diastolic (bottom number). The rest of the patient's vital signs (temperature, pulse rate and respiratory rate) were within a normal range. There were no admissions to the hospital, no episodes of falls and no evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. d. A review of Patient 7's clinical record indicated a start of care date (SOC) of 11/4/22, with diagnoses which included essential hypertension (high blood pressure). A review of Patient 7's Home Health Certification and Plan of Care (POC) for the certification period starting from 11/4/22 to 1/3/23, included an order for the skilled nurse (SN) to visit Patient 6 once a week for nine weeks, to observe and reassess: Homebound status, cardiovascular status, endocrine status, and hydration/nutrition status. Medication compliance and perform vital signs check. The POC indicated to notify the physician if Patient 7's blood pressure (BP) is below 90/60 or above 155/90, or if heart rate is below 50 beats per minute (bpm) or above 100 bpm, and pain is above seven on a pain scale of 1-10 (0: no pain, 10: unbearable pain). The listed goal indicated Patient 6 will do the following: Demonstrate compliance with medications. Maintain BP in range of 120-150/60-90 mm Hg. Demonstrate home safety measures. Skin integrity will be maintained without any form of infection or skin breakdown. Discharge planning indicated to discharge when goals are met, when patient no longer in need of skilled services, and when patient reaches maximum functional potential. On 5/3/23, at 11:40 a.m., a home visit was conducted to Patient 7's residence with LVN 1. Patient 7 was observed sitting on the couch, alert, oriented and ambulatory using a walker. On 5/3/23 at 11:45 a.m., during an interview with Patient 7's primary caregiver (son), he stated that he prepares the patient's medications and administer it to him regularly, monitors his blood sugar daily, and takes him to his physician every couple of months. He also stated that Patient 7 does not have any body ache, headache or pain, no falls, no hospitalization, and does her activities of daily living (ADLs, like bathing, toileting, dressing, eating, mobility) independently and/or with assistance by himself. A review of Patient 7's Clinical Nursing Notes from 11/4/23 to 1/3/23 indicated Patient 7’s blood pressure ranged from 121-125 systolic (top number) and 79-86 diastolic (bottom number). The rest of the patient's vital signs (temperature, pulse rate and respiratory rate) were within a normal range. There were no admissions to the hospital, no episodes of falls and no evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. e. A review of Patient 8's clinical record indicated a start of care date (SOC) of 1/10/23, with diagnoses which included essential hypertension (high blood pressure). A review of Patient 8's Home Health Certification and Plan of Care (POC) for the certification period starting from 1/10/23 to 3/10/23, included an order for the skilled nurse (SN) to visit Patient 8 once a week for nine weeks, to observe and reassess: Homebound status, cardiovascular status, endocrine status, and hydration/nutrition status. Medication compliance and perform vital signs check. The POC indicated to notify the physician if Patient 8's blood pressure (BP) is below 90/60 or above 155/90, or if heart rate is below 50 beats per minute (bpm) or above 100 bpm, and pain is above seven on a pain scale of 1-10 (0: no pain, 10: unbearable pain). The listed goal indicated Patient 8 will do the following: Demonstrate compliance with medications. Maintain BP in range of 120-150/60-90 mm Hg. Demonstrate home safety measures. Skin integrity will be maintained without any form of infection or skin breakdown. Discharge planning indicated to discharge when goals are met, when patient no longer in need of skilled services, and when patient reaches maximum functional potential. On 5/3/23, at 1p.m., a home visit was conducted to Patient 8's residence with LVN 2. Patient 8 was observed sitting on her chair in the living room, alert, oriented and ambulatory using a cane. On 5/3/23 at 1:15 p.m., during an interview with Patient 8, she stated she drives her car and goes to aa adult day care center three times a week. She also stated that she uses a thread mill at the adult day care center for jogging and lost 60 pounds during the past few months. She also stated that she takes her medications regularly, monitors her blood sugar daily, and drives herself to her physician every couple of months. She also stated that she does not have any body ache, headache or pain, no falls, no hospitalization, and does her activities of daily living (ADLs, like bathing, toileting, dressing, eating, mobility) independently. A review of Patient 8's Clinical Nursing Notes from 1/10/23 to 3/10/23 indicated Patient 8’s blood pressure ranged from 122-127 systolic (top number) and 68-72 diastolic (bottom number). The rest of the patient's vital signs (temperature, pulse rate and respiratory rate) were within a normal range. There were no admissions to the hospital, no episodes of falls and no evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. f. A review of Patient 9's clinical record indicated a start of care date (SOC) of 8/9/22, with diagnoses which included essential hypertension (high blood pressure). A review of Patient 9's Home Health Certification and Plan of Care (POC) for the certification period starting from 2/5/23 to 4/5/23, included an order for the skilled nurse (SN) to visit Patient 9 once a week for nine weeks, to observe and reassess: Homebound status, cardiovascular status, endocrine status, and hydration/nutrition status. Medication compliance and perform vital signs check. The POC indicated to notify the physician if Patient 9's blood pressure (BP) is below 90/60 or above 155/90, or if heart rate is below 50 beats per minute (bpm) or above 100 bpm, and pain is above seven on a pain scale of 1-10 (0: no pain, 10: unbearable pain). The listed goal indicated Patient 9 will do the following: Demonstrate compliance with medications. Maintain BP in range of 120-150/60-90 mm Hg. Demonstrate home safety measures. Skin integrity will be maintained without any form of infection or skin breakdown. Discharge planning indicated to discharge when goals are met, when patient no longer in need of skilled services, and when patient reaches maximum functional potential. A review of Patient 9's Clinical Nursing Notes from 2/5/23 to 4/5/23 indicated Patient 9’s blood pressure ranged from 133-141 systolic (top number) and 74-84 diastolic (bottom number). The rest of the patient's vital signs (temperature, pulse rate and respiratory rate) were within a normal range. There were no admissions to the hospital, no episodes of falls and no evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. A review of the agency’s undated policy and procedure titled, "Client Discharge Process", indicated discharge planning is initiated for every home care client at the time of the client’s admission for home care. The Client shall be discharged from home health services on the basis of reasonable criteria which includes the client has reached defined goals and is no longer in need of home care.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to update the medication profile (the information about the medication a person is using and has used) to reflect the patient's current medications for two of 10 sampled patients (Patient 1 and Patient 2). This deficient practice has the potential to place the patient at risk for medication errors and adverse (serious) drug reactions. Findings: a. A review of Patient 1's clinical record indicated a start of care date of 7/28/2022, with diagnoses including pressure ulcer of sacral region, Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Patient 1's Home Health Certification and Plan of Care (POC) for the recertification period from 3/25/2023 to 5/23/2023, included an order for the skilled nurse (SN) frequency of visits of twice a week for 9 weeks, to assess all body systems, assess vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level, medication and diet compliance, and safety on every visit. On 5/03/2023, at 10:10 a.m., a joint home visit was conducted at Patient 1's residence with the DPCS Designee (DPCSD). Patient 1 was observed laying in a hospital bed awake but confused. Patient’s family member (FM 1) was present at bedside. On 5/03/2023 at 10:50 a.m., a concurrent review of Patient 1's medications was conducted with DPCSD and an interview with FM 1. The following was observed: The medication profile that was provided by the agency indicated, Patient 1 was taking Norco 5mg-325mg(milligram) 1 tablet by mouth every 6 hours as needed for severe pain, and Allopurinol (a medication used to treat gout and prevent or lower high uric acid levels in the blood) 100 mg 1 tablet by mouth daily. FM 1 stated Patient 1 stopped taking these medication for several months as ordered by the physician. b. A review of Patient 2's clinical record indicated a start of care date of 2/22/2022, with diagnoses which included type 2 diabetes mellitus, end stage renal disease (when the kidneys are no longer able to function normally), and dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to). A review of Patient 2's Home Health Certification and Plan of Care (POC) for the certification period starting from 2/17/2023 to 4/17/2023, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, to assess all body systems, assess vital signs, pain level, severe shortness of breath, blood sugar check (measures the level of glucose in your blood), medication and diet compliance, and safety on every visit. On 5/03/2023, at 11:55 a.m., a joint home visit was conducted at Patient 2's residence with the DPCS Designee (DPCSD). Patient 2 was observed sitting up in chair, alert and oriented, and ambulatory using a cane, accompanied by the patient’s caregiver (PCG 1). On 5/03/2023 at 12:20 p.m., a concurrent review of Patient 2's medications was conducted with DPCSD and an interview with Patient 2. The following was observed: The medication profile that was provided by the agency indicated Patient 2 was taking Clonidine hydrochloride (an antihypertensive drug that lowers blood pressure and heart rate by relaxing the arteries and increasing the blood supply to the heart) 0.1 mg tablet by mouth every 6 hours as needed for systolic blood pressure higher than 160, Lasix (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) 80 mg 1 tablet by mouth at bedtime, and Vitamin D3 2000 units 1 soft gel by mouth daily. Patient 2 stated he stopped taking these medications for several months. On 5/03/2023, at 12:30 p.m., during an interview with the DPCSD, he stated the agency’s skilled nurse has to check the patient's medications on every visit for changes and update the patient's medication profile to reflect the changes. A review of the agency's policy and procedure titled "Medication Profile", revised November 2022, indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

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 interview and record review, the Home Health Agency (HHA) failed to implement interventions and re assess pain management in accordance with the plan of care for one of 10 sampled patients (Patient 1). This deficient practice has the potential to result in ineffective pain management. Findings: A review of Patient 1's clinical record indicated a start of care date of 7/28/2022, with diagnoses including pressure ulcer of sacral region, Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Patient 1's Home Health Certification and Plan of Care (POC) for the recertification period from 3/25/2023 to 5/23/2023, included an order for the skilled nurse (SN) frequency of visits of twice a week for 9 weeks, to assess all body systems, assess vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), medication and diet compliance, and safety on every visit. The POC also indicated for the SN to assess pain level using subjective and objective observation before and after each treatment/medication using universal pain scale of 0-10 (0 being no pain and 10 being the worst pain). The goal included the patient’s musculoskeletal status will improve as evidenced by increased in strength, endurance, mobility, and decreased pain to a tolerable level 1-2/10 with the aid of pain medication and non-pharmacologic methods. A review of Patient 1's SN Visit Note dated 3/29/2023, 4/05/2023, 4/12/2023 and 4/14/2023, indicated Patient 1 was experiencing pain 5/10, location indicated “all body”. There was no documented evidence of interventions and reassessment done for the pain. On 5/04/2023, at 1:15 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), she stated, pain assessment has to include the intervention for pain management, the effectiveness of the intervention and pain reassessment using the pain level 0-10. DPCS stated, Patient 1 did not have pain assessment and pain management intervention. A review of the agency's policy and procedure titled "Pain Management”, revised November 2022, indicated healthcare clinicians plan, support, and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed appropriately. Pain will be assessed as a part of every patient contact if the patient reports pain or is at risk for pain. Patients who report pain will receive further assessment and appropriate management. A review of the agency's policy and procedure titled "Care Planning Process", revised November 2022, indicated the patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and the services required to meet the patient’s needs.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure the plan of care (POC) covered all pertinent diagnoses for one of 10 sampled patients (Patient 2). For Patients 2, who receives hemodialysis (a procedure that performs the functions of the kidneys in people whose kidneys failed) treatment and has arteriovenous access site (AV fistula, a connection of a vein and an artery through a surgical procedure, used during hemodialysis). The staff did not document the care needed to monitor the access sites. This deficient practice had the potential to put the patient at risk for complications that includes bleeding, infection, blood clots or problems at the hemodialysis access site. Findings: A review of Patient 2's clinical record indicated a start of care date of 2/22/2022, with diagnoses which included type 2 diabetes mellitus, end stage renal disease (when the kidneys are no longer able to function normally), and dependence on renal dialysis (a treatment to clean the blood when the kidneys are not able to). A review of Patient 2's Home Health Certification and Plan of Care (POC) for the certification period starting from 2/17/2023 to 4/17/2023, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, to assess all body systems, assess vital signs, pain level, severe shortness of breath, blood sugar check (measures the level of glucose in your blood), medication and diet compliance, and safety on every visit. There were no instructions in the POC for renal dialysis care/management, including AV access site monitoring for bleeding/infection, assessing for bruit (audible vascular sound associated with turbulent blood flow usually heard with the stethoscope) and thrill (vibration accompanying a vascular murmur that can be palpated), instruction regarding fluid restriction, emergency bleeding situation, etc. On 5/03/2023, at 11:55 a.m., a joint home visit was conducted at Patient 2's residence with the Director of Patient Care Services Designee (DPCSD). Patient 2 was observed sitting in a chair, alert and oriented, and ambulatory using a cane, accompanied by the patient’s caregiver (PCG 1). Patient 2 had an AV fistula on the left forearm. DPCSD was observed not checking Patient 2’s AV fistula for bruit and thrill during the visit. On 5/04/2023, at 12:30 p.m., during a concurrent interview and record review with the DPCSD, he stated there was no POC developed regarding renal dialysis care and management, including AV access site assessment/monitoring of Patient 2. DPCSD stated the POC should have included all the care/services the patient needed. A review of the agency's policy and procedure titled "Care Planning Process", revised November 2022, indicated the patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the nursing staff provided instructions or health teaching for one of 10 patients (Patient 9). This deficient practice placed the patient/caregiver with a potential risk for not acquiring correct blood sugar (BS) readings while using their glucometer. A review of Patient 9's clinical record indicated a start of care date (SOC) of 8/9/22, with diagnoses which included essential hypertension (high blood pressure). A review of Patient 9's Home Health Certification and Plan of Care (POC) for the certification period starting from 4/6/23 to 6/4/23, included an order for the skilled nurse (SN) to visit Patient 9 once a week for nine weeks, for assessment of all body system and medication compliance. One of the SN interventions was to teach patient/caregiver in blood glucose monitoring and how to perform how to use the glucometer the proper way. A review of Patient 9's SN Visit Note dated 4/7/23 indicated a blood sugar reading of 120 mg/dl taken by the patient's caregiver. A review of Patient 9's clinical record indicated no documented evidence the visiting nurse provided patient teaching on glucometer usage with a return demonstration by the patient/caregiver to validate teaching. On 5/4/23, at 12 p.m., during an interview with the DPCSd (director of patient care services designee), he stated the visiting nurse should be teaching regarding glucometer usage and patient/caregiver should do a return demonstration to the visiting nurse to show proper way and to validate the teaching. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to ensure the patient's medical records were stored and safeguarded against loss and or unauthorized use. This deficient practice placed the patient's clinical records at risk to be seen by unauthorized users. On 5/2/23, at 2 p.m., during an initial tour of the agency, there were several patient's medical records that were stacked in pile from the ground and up in one adjacent room. The agency could not find the keys for their storage cabinets that stored their 102 active patient's medical record charts. At 2:30 p.m., during an interview with the DPCSD (director of patient care services designee), he stated that he could not find the keys to lock the steel cabinets and he stated the discharged records of different patients observed on the ground in the agency, has to be stored in a box and supposed to be sent to their storage room for filing. A review of agency's policy " Protection of Records", indicated that medical records should be stored in cabinets locked if not in use.