Every finding on record at Interim Healthcare of Northern California

The following reflects the findings of the California Department of Public Health during a Federal Recertification survey conducted from 2/4/25 through 2/7/25. This Federal Recertification survey was a review of all federal regulations related to the operation of a Home Health agency and represents a full inspection of this agency. Admissions (unduplicated, for a 12-month period): 364. Current Census: 105 Sample Size: 10 Home Visits: 4 All Conditions of Participation were Met.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure that three of 10 sampled patients (Patient 1, 4, and Patient 8), was evaluated by a discipline ordered by the referring physician, and was included in the Plan of Care (POC) when: 1. Patient 1, and Patient 4 did not receive a Medical Social Worker (MSW) evaluation to assess needs during home health services per orders. 2. Patient 8 did not receive a Physical Therapist (PT) evaluation to assess needs during home health services per orders. This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. Findings: A review, of the agency’s policy dated 4/2/21, titled, “Implementing the Plan of Care/Service Plan,” indicated the purpose of this policy is to ensure that the written plan of care is implemented. The Director of Health Care Services ensures resources are available, and processes are in place to implement the Plan of Care/Plan of Service. Patient 1’s clinical record was reviewed. Patient 1 was admitted to the home health agency on 12/11/24, with diagnoses that included pressure injury (any disruption of the intact skin with underlying damage to the tissues), polyneuropathy (nerve pain), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), kidney disease, hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed), and hyperglycemia (too much sugar in the blood). During a review, of Patient 1’s clinical record, the POC dated 12/11/24, indicated a Medical Social Worker (MSW) ordered for the week of 12/16/24 to evaluate needs. During a review, of Patient 1’s clinical record, there were no MSW visits for Patient 1 completed, and no updates to the physician for missed visits for the MSW. During an interview, on 2/6/25 at 11:10 am, the Director of Nursing (DON) confirmed, that the MSW did not complete any visits for Patient 1, and the physician was not updated with the change in POC. The DON stated, “I confirm Patient 1 needed a MSW because we filed an Adult Protective Services Report at the discharge. The MSW did try to go on the last day 1/6/25, but the caregiver refused.” Patient's 4 clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s clinical record, the POC dated 12/31/24, indicated a MSW order for community resources, and to assist with long term planning and caregiving. During a review, of Patient 4’s clinical record, there were no MSW visits for Patient 4 completed, and no updates to the physician for missed visits for the MSW. During an interview, on 2/5/25 at 1:30 pm, Registered Nurse (RN) 5 confirmed, that the MSW did not complete any visits for Patient 4, and the physician was not updated. RN 5 stated, “We did not have a MSW, and I should have updated the physician at that time.” During an interview, on 2/6/25 at 10:58 am, the Director of Nursing (DON) confirmed the MSW did not complete any visits for Patient 4, and the physician was not updated the change in POC. DON stated, “We just hired a new MSW, and she starts in two weeks.” Patient 8's clinical record was reviewed. Patient 8 was admitted to the home health agency on 5/9/24, with diagnoses that included open wound to the abdominal wall (stomach), acute respiratory failure (condition when the lungs cannot exchange oxygen) with hypoxia (low oxygen levels in the blood), Congestive heart failure (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), liver disease, and hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed). During a review, of Patient 8’s clinical record, the POC dated 5/9/24, included a Physical Therapist (PT) order for an evaluation for the week of 5/13/24, to evaluate and treat as indicated. During a review, of Patient 8’s clinical record, there were no PT visits for Patient 8 completed, and no updates to the physician for missed visits for the PT from 5/9/24 to 7/7/24. During an interview, on 2/6/24 at 2:35 pm, the Director of Nursing (DON) confirmed, that there were no PT visits for the certification period from 5/9/24 to 7/7/24, for Patient 8, and this did not follow the POC. The DON also confirmed the physician had not been updated.

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 interview, and record review, the agency failed to ensure that three of 10 sampled patients (Patient 3, 4, and Patient 5), was assessed by a Registered Nurse (RN) within 48-hours of their referral for home health care, and to notify the physician when there was a delayed start of care (admission to agency). This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. Findings: During a review of the agency’s policy dated 4/2/21, titled, “Initial Comprehensive Assessment,” indicated an initial comprehensive assessment of an individual is conducted within 48 hours of referral for home care/services, or within 48 hours of the individual’s return home, or the physician’s or allowed practitioner ordered start of care (SOC) date. If the initial comprehensive assessment cannot be completed within the time frame agreed upon at the referral, the ordering physician or practitioner is contacted for an order for an alternate date. During a review of Patient 4’s clinical record, Patient 4 was admitted to the home health agency on 10/10/24 with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s visit documentation, it was noted that Patient 4 was referred to services on 10/7/24, but the start of care (initial comprehensive assessment) date was 10/10/24 (3 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent record review, and interview, on 2/7/25 at 11:45 am, Registered Nurse (RN) 2 confirmed there was no documentation of a reason for the delay of the start of care, and no update sent to the physician to notify that services were delayed for Patient 4. During an interview on 2/7/25 at 12:30 pm, the Director of Nursing confirmed that it was the expectation and policy of this agency, as well as a Federal regulation, to open all patients to service within 48-hours of their referral date, and to notify the physician if there was a delay. During a review of Patient 3’s record, Patient 3 was admitted to the home health agency on 11/14/2023 with diagnoses that included chronic venous hypertension (condition where the pressure in the leg veins is high,) wounds on both legs, and gout (a type of arthritis.) During a review of Patient 3’s clinical record, it was noted that a referral for home health services was received by the agency on 11/8/2023. The start of care for Patient 3 was 11/14/2023. There was no documentation to clarify the delay or indicate the physician had been notified in a timely manner. During a concurrent record review and interview on 2/6/25 at 2:40 pm with the DON she confirmed that Patient 3’s start of care was not within 48 hours of the agency receiving the referral. During a review of Patient 5’s record, Patient 5 was admitted to the home health agency on 10/18/2024 with diagnoses that included a wound of the left lower leg, chronic pain, and chronic obstructive pulmonary disorder (COPD, lung disease that makes it difficult to breathe). During a review of Patient 5’s clinical record, it was noted that a referral for home health services, labeled “Urgent” was received by the agency on 10/10/2024. The start of care for Patient 5 was 10/18/2024. There was no documentation to clarify the delay or indicate the physician had been notified in a timely manner. During an interview and concurrent record review on 2/4/25 at 4:30 pm with the scheduler (SD,) she confirmed that the referral for Patient 5 was received by the agency on 10/10/2024 and that the start of care was 10/18/2024. SD stated that, due to the type of insurance Patient 5 had, staff wait to receive notification of authorization before any visits can be scheduled, including start of care. SD verified that the agency received authorization on 10/15/2024, and the start of care visit did not occur until 10/18/2024. During a concurrent interview and record review on 2/5/25 at 2 pm with DON, she confirmed that the start of care visit for Patient 5 did not occur in a timely manner. DON clarified that all start of care assessments should occur within 48 hours of the agency receiving a patient referral.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to review and document all medications in the home for one out of 10 sampled patients, (Patient 8) during a home visit to include in the clinical record and for the physician to review for interactions. This failure had the potential to cause unrecognized medication interactions, which could cause potential negative clinical outcome. Findings: The agency’s policy titled, “Medication Reconciliation/Drug Interactions," undated, indicated that when performing a visit, a medication reconciliation must be completed, and if a home medication(s) does not match the agency’s medication list, a medication reconciliation must be completed. If a patient notifies the nurse that they are taking a new medication, or the directions on how they are taking a medication has changed, a medication reconciliation must be completed at that time also. Patient 8's clinical record was reviewed. Patient 8 was admitted to the home health agency on 5/9/24, with diagnoses that included open wound to the abdominal wall (stomach), acute respiratory failure (condition when the lungs cannot exchange oxygen) with hypoxia (low oxygen levels in the blood), Congestive heart failure (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), liver disease, and hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed). During an concurrent observation, interview, and record review, on 2/5/25 at 12:28 pm, with Registered Nurse (RN) 3 , the medications in the home did not match the medication list created on 2/5/25, from Patient 8’s medication profile for Home Health Episode 1/4/25 – 3/4/25. RN 3 stated, “I ask about medications every visit, and if there are any changes, I will update the medication list.” During an interview, on 2/5/25 at 12:30 pm, Patient 8 stated, “I get busy, and don’t remember new medications, or changes in my medications sometimes.” During a review, of Patient 8’s medication profile dated 2/5/25, for Home Health Episode1/4/25 – 3/4/25, it noted that Patient 8’s medication profile had 10 medications that were either no longer being taken, days when a medication was scheduled to be taken had changed, or new medications/supplements were not added. During an interview, on 2/6/25 at 8:53 am, the Director of Nursing (DON) confirmed, that the medication profile was not accurate and up to date for Patient 8. When asked what the expectations are for medication reconciliation, the DON stated, “The medication reconciliation should be performed at each visit by the nurse.”

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure one of 10 sampled patients (Patient 4) had a Resumption of Care (ROC, a Registered Nurse assessment for the patient to resume care and home health orders) completed after a hospitalization within 48-hours. This failure could result in another hospitalization, delay in obtaining physician oversight, and other negative clinical outcomes. Findings: The agency’s policy dated 4/2/21, titled, “Resumption of Care,” indicated the policy for all employees to conduct an individual comprehensive assessment of all patients within 48-hours of (or knowledge of) the patient’s return home from an inpatient or hospital stay of 24-hours or more for any reason except diagnostic tests; or the physician ordered resumption of care (ROC) date. Patient 4's clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s clinical record, a document dated, 12/25/24, titled, “Discharge Orders,” indicated that Patient 4 was admitted to a local hospital on 12/15/24, for severe sepsis, (the body’s extreme response to an infection), hypernatremia (too much sodium in the blood), hypokalemia (not enough potassium in the blood), pneumonia (infection in the lungs) and a Urinary Tract Infection (UTI, a bladder infection). This record also indicated, that Patient 4 was discharged on 12/25/24. During a review, of Patient 4’s clinical record, a document dated, 12/27/24, titled, “Missed Visit,” indicated Patient 4 was no longer at a local hospital entered by Registered Nurse (RN) 5 on 12/27/24 at 10:00 am. During a review, of Patient 4’s clinical record, there were no physician notifications of Patient 4 returning home from a hospitalization, or a ROC request date order. During an interview, on 2/4/25 at 3:40 pm, RN 5 confirmed the ROC was late for Patient 4. RN 5 stated, “I confirm the ROC was late, we have to call the doctor, and the ROC was not completed until 12/31/24. I did not call the doctor to update.” During an interview, on 2/4/25 at 4:15 pm, the Director of Nursing (DON) confirmed, that the ROC was late for Patient 4, completed on 12/31/24, six days after Patient 4 was discharged home on 12/25/24.

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 agency failed to include all treatments, pertinent diagnoses specific interventions and goals as relevant to the plan of care for three out of 10 sampled patients, (Patient 1, Patient 4, and Patient 10). This failure had the potential for unidentified problems, risk for hospitalization and negative clinical outcomes. Findings: During a review, of the agency’s policy dated 4/2/21, titled, “Developing a Plan to Meet Patient/Client Needs,” it indicated an individualized plan of care (POC) is developed for each patient receiving care/services to specify the care and services necessary to meet the patient’s specific needs and goals as identified in the comprehensive assessment. The development and evaluation of the plan of care in partnership of the patient, representative, and care givers. The POC directs the delivery of care/service. Care/Services are furnished in accordance with accepted standards of practice, law, and regulation. Patient 1's clinical record was reviewed. Patient 1 was admitted to the home health agency on 12/11/24, with diagnoses that included pressure injury (any disruption of the intact skin with underlying damage to the tissues), polyneuropathy (nerve pain), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), kidney disease, hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed), urinary device (Foley Catheter, (F/C) a tube inserted into the bladder to drain urine) and hyperglycemia (too much sugar in the blood). During a review, of Patient 1’s plan of care (POC, or physician orders that help nurses and other team members organize aspects of patient care with a timeline) dated 12/11/24, indicated there was no date of last change of F/C for Skilled Nurse (SN) listed. There were no interventions listed for education related to turning and positioning for prevention of more wounds. The POC did not provide education for care giver strain for 24/7 care needed or any community resources to assist for Patient 1, while waiting on a Medical Social Worker (MSW) visit that was not completed. During an interview, on 2/4/25 at 11:58 am, the Director of Nursing (DON) confirmed the MSW visit was never completed per the POC, and the care giver needed education for Patient 1. The DON confirmed, that the SN interventions were not specific to Patient 1’s medical needs and for education the care giver needed. DON stated, "We should have increased the SN visits, and revised the POC, when the MSW did not go to the home." During a review of Patient 4’s clinical record, Patient 4 was admitted to the agency on 10/10/24 with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s plan of care POC dated 10/10/24, it indicated there were no interventions for SN to complete care for the G/T, care giver education was not listed for the G/T, and signs and symptoms of infection of the G/T site to report to the agency and physician, as indicated were not listed. There was no education interventions related to keeping head of the bed elevated during feedings, and water administration via G/T. During a review of Patient 4’s clinical record, a document dated, 12/25/24, titled, “Discharge Orders,” indicated Patient 4 was admitted to a local hospital on 12/15/24 for severe sepsis, (the body’s extreme response to an infection), hypernatremia (too much sodium in the blood), hypokalemia (not enough potassium in the blood), pneumonia (infection in the lungs) and a Urinary Tract Infection (UTI, a bladder infection). This record also indicated Patient 4 was discharged on 12/25/24. During an interview on 2/5/24 at 1:40 pm, Registered Nurse (RN) 5 stated, “I agree I should have added G/T interventions for the Skilled Nurse (SN) to observe the G/T site. I place a dry 4 x 4 slit gauze at every visit to [Patient 4’s] G/T site. The care givers do need more education of what to report to the agency, and physician. They also need more education for pain management, turning and repositioning.” Patient 10's clinical record was reviewed. Patient 10 was admitted to the home health agency on 1/8/25, with diagnoses that included sepsis (a severe reaction to an infection), open wound to left chest, diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), history of a myocardial infarction (heart attack), kidney disease and history of venous thrombosis (blood clot forms in a vein) and embolism (a blood clot that travels to the lungs, suddenly forms a blockage). During a review, of Patient 10’s plan of care POC dated 1/8/25, it indicated there were no orders or interventions for wound care if the wound vac (vac, machine used for wound healing with specific settings) was not functioning, no specific alternate wound care orders for SN, or care givers. This POC did not have orders, or interventions for education for signs and symptoms of infection related to a prolonged hospitalization with a wound infection. There were no orders, or interventions for education related to heart disease, or new onset of chest pain, and Patient 10 had a history of a heart attack. During an interview, on 2/5/25 at 12:30 pm, RN 2 confirmed, that all POCs need to be patient specific. RN 2 confirmed, that wound care order alternates should be on the POC for Patient 10. RN 5 confirmed, that G/T SN and caregivers' orders, and interventions should be on the POC for Patient 4. During an interview, on 2/7/25 at 12:20 pm, the DON confirmed all POCs need to be patient specific and there will be more education provided to make all POCs more detailed for each diagnosis pertinent to home health, and for each intervention completed by SN.

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: Based on interview, and record review, the agency failed to identify and update the physician of a significant change in condition for one of 10 sampled patients (Patient 4). This failure resulted in poor pain management, a hospitalization, and negative clinical outcomes. Findings: During a review, of the agency’s policy dated 4/2/21, titled, “Coordination of Care/Services,” is to facilitate coordination and continuity of care/service for patients/clients from time of referral through discharge. The Interdisciplinary Team (IDT, a group of health care professionals from diverse fields, physicians, allowed practitioners, nurses, therapists, home health aides, and social workers) who work in a coordinated fashion toward a common goal for the patient. The Director of Health Care Services (DHCS) establishes a process to integrate care/services, whether provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician or allowed practitioners. The DHCS establishes processes for the documentation of IDT coordination of care in the patient/client record. This agency’s policy also indicated the designated employee contacts the physician or practitioner when any of the following events occur: The patient’s condition changes, the patient’s response to care/treatment changes or medications is not as expected, and changes occur in care giver support or the patient’s environment that impacts the plan of care/service plan. Patient 4's clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s plan of care (POC, or physician orders that help nurses and other team members organize aspects of patient care with a timeline) dated 10/10/24, indicated there were no wounds (open areas of skin), no pain indicated or documented and no contractures. There was an order for Tylenol (a medication for mild pain or fever) 325 milligrams (mg, a unit of measure) 1 tablet two times daily as needed for pain via gastrostomy (G/T). During a review, of Patient’s 4 clinical record a document dated 12/12/24, titled, “Visit Note,” it indicated under pain status, patient had non-verbal symptoms of pain as follows: grimacing, moaning, and was restless. During a review, of Patient 4’s Resumption of Care Outcome and Assessment Information Set (Oasis) dated 12/31/24, J0520 question for pain status indicated Patient 4 does have pain frequently with limitation to therapy activity. This Oasis also indicated J0530 question for pain interference to daily activities is frequently for Patient 4. During a review, of Patient 4’s POC dated 12/31/24, for a resumption of care through 2/6/24, indicated new wounds, no Tylenol was listed on the medication list, or any other pain medications. During a review, of Patient 4’s clinical record, there were no physician updates documented, or faxed for Patient 4’s pain, new onset of wounds, and no change of condition or decline Oasis documented from 10/10/24 to 2/5/25. During an interview, on 2/5/25 at 12:30 pm, Registered Nurse (RN) 5 confirmed, that Patient 4 did have a change in condition and this Oasis was not completed, and the physician was not notified of increased pain during positioning. RN 5 stated, “Yes, I confirm [Patient 4] has had a decline, he has more pain, he wants to stay on his right side, he does moan and grimace during repositioning, and seven new wounds from pressure. He is also getting contractures from not getting out of bed often, and [Patient 4] lies in a fetal position most of the time. I am doing the recertification due tomorrow for Patient 4 and will update the physician of the decline and ask for something for pain management.” During an interview, on 2/7/25 at 11:55 am, RN 2 confirmed, that the physician should have been updated with the changes and decline for Patient 4. RN 2 also stated, “I don’t know which Oasis we use for a change of condition, but I will find it. I agree [Patient 4] needed a significant change of condition Oasis completed for pain, new wounds, and decreased range of motion.” During an interview, on 2/7/25 at 12:05 pm, the Director of Nursing (DON) confirmed, that Patient 4 had a change of condition and new pain that was not reported to the physician. The DON also confirmed, that a change of condition Oasis should have been completed for Patient 4. The DON stated, “The change of condition can be any decline, I know Patient 4 is declining, and is nothing by mouth (NPO), but he could have taken more supplements for new wounds via G/T.”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure that 10 out of 10 patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and Patient 10) had Interdisciplinary team (IDT, a group of health care professionals who work together to provide care for the patient) ongoing assessments documented in the clinical record to ensure the coordination of all services and interventions provided to the patient to include all physician orders, and the communication of progress and ongoing problems. This failure had the potential for unrecognized needs to go unmet which could lead to potential negative clinical outcomes. During a review of Patient 2’s record, Patient 2 was admitted to the home health agency on 8/22/24 with a diagnosis of chronic wound. During a review of Patient 2’s clinical record, there were no IDT notes documented in Patient 2’s clinical record from 8/22/24 through 12/19/2024 when the patient was discharged. During a review of Patient 3’s record, Patient 3 was admitted to the home health agency on 11/14/23 with diagnosis that included chronic venous hypertension (condition where the pressure in the leg veins is high,) wounds on both legs, and gout (a type of arthritis.) During a review of Patient 3’s clinical record, there were no IDT notes documented in Patient 3’s clinical record from 11/14/23 through 1/6/25 when the patient was discharged. During a review of Patient 5’s record, Patient 5 was admitted to the home health agency on 10/18/2024 with diagnoses that included a wound of the left lower leg, chronic pain, and chronic obstructive pulmonary disorder (COPD, lung disease that makes it difficult to breathe). During a review of Patient 5’s clinical record, there were no IDT notes documented in the record from 10/18/24 through 2/4/2025 at the time of review During a review of Patient 7’s record. Patient 7 was admitted to the home health agency on 5/15/24 with diagnoses that included a diabetic foot wound, cellulitis (a bacterial skin infection that causes swelling and redness,) and chronic pain. During a review of patient 7’s clinical record. There were no IDT notes documented in the record from 5/15/24 through 2/4/25 at the time of review. Findings: During a review of the agency’s policy dated 4/2/21, titled, “Coordination of Care/Services,” is to facilitate coordination and continuity of care/service for patients/clients from time of referral through discharge. The Interdisciplinary Team (IDT, a group of health care professionals from diverse fields, physicians, allowed practitioners, nurses, therapists, home health aides, and social workers) who work in a coordinated fashion toward a common goal for the patient. The Director of Health Care Services (DHCS) establishes a process to integrate care/services, whether provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician or allowed practitioners. The DHCS establishes processes for the documentation of IDT coordination of care in the patient/client record. During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 12/11/24 with diagnoses that included pressure ulcer (any disruption of the intact skin with underlying damage to the tissues), polyneuropathy (nerve pain), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), kidney disease, hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed), and hyperglycemia (too much sugar in the blood). During a review of Patient 1’s clinical record, there were no IDT notes documented in Patient 1’s clinical record from 12/11/24 through 1/6/25, when Patient 1 was discharged from the agency. During a review of Patient 4’s clinical record, Patient 4 was admitted to the home health agency on 10/10/24 with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review of Patient 4’s clinical record, there were no IDT notes documented in Patient 4’s clinical record from 10/10/24 through 2/6/25. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency on 1/16/25 with diagnoses that included congestive heart failure, (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), pulmonary hypertension (a condition that affects blood vessels in the lungs with increased pressure), pulmonary embolism (a blood clot that travels to the lungs, suddenly forms a blockage), history of kidney stones and bladder cancer. During a review of Patient 6’s clinical record, there were no IDT notes documented in Patient 6’s clinical record from 1/16/25 through 2/6/25. During a review of Patient 8’s clinical record, Patient 8 was admitted to the home health agency on 5/9/24 with diagnoses that included open wound (any disruption of the intact skin with underlying damage to the tissues) to the abdominal wall, acute respiratory failure (condition when the lungs cannot exchange oxygen) with hypoxia (low oxygen levels in the blood), Congestive heart failure (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), liver disease, and hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed). During a review of Patient 8’s clinical record, there were no IDT notes documented in Patient 8’s clinical record from 5/9/24 through 2/6/25. During a review of Patient 9’s clinical record, Patient 8 was admitted to the home health agency on 10/1/24 with diagnoses that included high blood pressure, congestive heart failure, (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), history of prostate cancer, personal history of nicotine (tobacco) dependence, and a history of falling. During a review of Patient 9’s clinical record, there were no IDT notes documented in Patient 8’s clinical record from 10/1/24 through 2/6/25. During a review of Patient 10’s clinical record, Patient 10 was admitted to the home health agency on 1/8/25 with diagnoses that included sepsis (a severe reaction to an infection), open wound (any disruption of the intact skin with underlying damage to the tissues) to left chest, diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), history of a myocardial infarction (heart attack), kidney disease and history of venous thrombosis (blood clot forms in a vein) and embolism (a blood clot that travels to the lungs, suddenly forms a blockage). During a review of Patient 10’s clinical record, there were no IDT notes documented in Patient 10’s clinical record from 1/8/25 through 2/6/25. During an interview on 2/6/25 at 12:03 pm, Registered Nurse 2 confirmed there were not IDT notes for 10 of 10 sampled patients in the clinical records. RN 2 stated, “There has been a lot of changes since the change in owners.” During an interview on 2/6/25 at 12:10 pm, the Director of Nursing (DON) confirmed no IDT notes were documented in the clinical records for any patients. DON stated, “We do discuss the residents, but we have not added any IDT notes in the electronic medical records. We will start this process immediately.”

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 interview, and record review, the agency failed to provide Registered Nurse (RN) oversight for a Home Health Aide (HHA) providing direct care in the home for one of 10 sampled patients, (Patient 4) every 14-days. This failure had the potential for Patient 4’s needs to go unidentified and ongoing needs to not be provided, which could lead to negative clinical outcomes. Findings: During a review, of the agency’s policy dated 1/13/18, titled, “Supervision of Employees Who Provides Patient Care Service," it indicated that the purpose of this policy is to define the scope and circumstance indicating in-person oversight of the employee who provides care/service to patients/clients. The nursing services are provided under the supervision of a qualified Registered Nurse (RN). During a review, of the agency’s policy dated 12/21/21, titled, “Case Supervision,” indicated the agency conducts regular cased supervision in accordance with applicable law and regulation and written contract for each patient. An appropriate qualified employee conducts case supervision onsite for each patient according to the following level of care required. Home Health Aide (HHA) Services with skilled services will be supervised no less frequently than every 14-days with or without the aide present. Patient 4's clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a record review, of Patient 4’s clinical record, Patient 4 had HHA visits weekly on 1/9/25, 1/16/25, 1/23/25, and 1/30/25. The last RN supervision of HHA was completed on 1/9/25, and no HHA supervision was completed on 1/23/25, or 1/30/25, per policy. During an interview, on 2/7/25 at 12:00 pm, RN 2 confirmed, that the HHA supervisory visits were late for Patient 4, and were not completed every 14-days per their agency’s policy. During an interview, on 2/7/25 at 12:15 pm, the Director of Nursing confirmed the HHA supervisory visits due every 14-days were late for Patient 4.

An Emergency Preparedness Survey was conducted by the California Department of Public Health (CDPH) from 7/25/22 through 7/28/22. The facility was in substantial compliance with the requirement of §484.102, Emergency Preparedness Condition of Participation for Home Health Agencies. Representing the Department: 40484, Health Facilities Evaluator Nurse (HFEN) 39737, HFEN 46147, HFEN Census (unduplicated, 12-month period): 383

The following reflects the findings of the California Department of Public Health during a Federal Recertification survey conducted 7/25/22 through 7/28/22. Representing the Department: 40484, Health Facilities Evaluator Nurse (HFEN) 39737, HFEN 46147, HFEN Census (unduplicated, 12-month period): 383 Sample Size: 10 Home Visits: 4 Records Reviewed: 10 All Conditions of Participation were met.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interview, and record review, the facility failed to document both the existence of complaints, and the resolution of complaints when the facility did not track complaints or use their established complaint forms, and managed complaints using staff discussion. This failure had the potential to prevent the timely perception of problem trends, and the prompt corrective action for problem areas, which could lead to loss of patient well-being. Findings: A review of a facility document titled, “Complaints,” dated 4/2/21, indicated that complaints and their resolution must be documented. During the entrance conference on 7/25/22 at 10 am, the Administrator (Admin) stated that complaints were not tracked. During an interview, on 7/27/22 at 2 pm, the Admin stated that although they have an established complaint form, it is no longer used. The Admin explained that the Home Care Supervisor takes the complaint call, and then discusses it with Admin. The Admin confirmed that they maintain no documentation, log, or other tracking mechanism to assist with complaint trends or patterns, or with QAPI.

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 observation, interview, and record review, the facility failed to follow accepted standards of practice to prevent the transmission of disease when: Bag technique was not followed during one of three observed home visits.Patient care equipment was not properly sanitized between patients. These failures had the potential to contribute to the transmission of disease among patients and staff, which could lead to negative clinical outcomes. Findings: 1. A review of a facility document titled, “Addendum M: Equipment/Supply Bag Techniques,” dated 3/13/15, indicated that the nursing bag is considered clean, and staff must wash their hands before entering the bag. When beginning a home visit, all supplies necessary for the visit must be removed from the bag, and placed on a clean surface. A review of a facility document titled, “Engineering Controls and Work Practices (continued),” with the subheading “Handwashing,” dated 4/5/19, indicated that staff must perform hand hygiene before, and after any patient care, before donning gloves, and after doffing them, and after contact with any contaminated material. During an observation, of a home visit on 7/25/22 at 1:40 pm, Licensed Nurse (LN) A was observed to measure the patient’s blood oxygen using her oximeter, then the LN replaced the unit in the nursing bag without performing hand hygiene. LN A then measured the patient’s temperature with her digital thermometer, retrieved the oximeter from the nursing bag without performing hand hygiene, and sanitized both instruments using the same disinfecting wipe before replacing both instruments in the nursing bag. Later in the visit, LN A sanitized her hands, donned gloves, and prepared wound care supplies. LN A then accessed the bag for additional supplies while wearing the clean gloves, then applied a new dressing to the patient’s wound while wearing the same gloves. Later in the visit, after LN A reapplied the patient’s socks and shoes, she doffed her gloves and donned new gloves without performing hand hygiene. Again, after examining the patient’s skin in the tailbone area, LN A doffed her gloves, then accessed the nursing bag without performing hand hygiene. During an interview, on 7/25/22 at 2:45 pm, LN A confirmed the breaches of bag technique as described above. 2. A review of a facility document titled, “Engineering Controls and Work Practices (continued),” with the subheading “Equipment/Supply Bag Technique,” dated 6/24/11, indicated that staff must clean patient care equipment with a disinfectant according to manufacturer’s recommendations after each use. During an observation, of a home visit on 7/25/22 at 1:40 pm, LN A was observed to disinfect the thermometer and oximeter using the same disinfecting wipe. LN A later used the same wipe to disinfect the blood pressure cuff and the stethoscope. Later in the visit, LN A disinfected the bandage scissors using a previously used disinfecting wipe. During an interview, on 7/25/22 at 2:45 pm, LN A stated that disinfecting wipes were not provided by the facility, and confirmed the repeated use of the same disinfecting wipe. During an interview, on 7/26/22 at 4:05 pm, the Home Health Aide (HHA) stated that the facility does not provide disinfecting wipes. During an interview, on 7/27/22 at 2 pm, the Administrator (Admin) confirmed that the facility does not provide staff with disinfecting wipes to use in the course of their work in the field.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview, and record review, the facility failed to develop and/or implement a policy and procedure (P&P) to ensure that all facility staff who provide any care, treatment, or other services for the facility and/or its patients are fully vaccinated for COVID-19 (an illness that can cause severe symptoms and in some cases death, especially in the elderly) when: The facility did not develop a process to accurately track staff COVID-19 vaccination status, to include initial doses of the vaccine and booster doses.The facility did not develop a process to track education given to staff who did not receive the vaccinations due to religious exemptions. These failures had the potential to put patients, staff, and the community at risk for infections, which could lead to negative clinical outcomes. Findings: A review of the facility policy titled “CMS COVID-19 Vaccination Mandate” with a revision date 1/2022, read, “The Administrator/Manager or designee creates a list of all eligible agency staff and develops a tracking log which tracks agency staff’s vaccination status…iv) Date and name of Booster dose(s), if received and recommended by the CDC.” The policy did not indicate education of staff if they were unvaccinated. 1. During a record review of the documentation provided by the facility regarding staff vaccination lists for COVID-19, it was noted that the clinical list of staff only contained information regarding the initial doses of the vaccine for COVID -19. The list of support staff for the facility, provided information regarding the initial doses and the booster doses. These lists also contain whether staff had received an exemption to the vaccine. During a concurrent interview and record review with the Administrator (Admin) on 7/27/22 at 8:55 am, she stated that she does not have a current list of boosted nursing staff (staff that have received the COVID-19 booster vaccines). During a concurrent interview and record review on 7/27/22 at 10:25 am, Admin confirmed the list is not up to date and in fact Licensed Nurse (LN) A was currently vaccinated for COVID–19. LN A was on the list as having an exemption. Admin showed documentation to indicate that LN A was vaccinated on 11/11/21 with the single dose vaccination. Admin also confirmed that LN H is not currently on this list. LN H works for both Hospice and Home Health. 2. During a concurrent interview and record review of the staff who have exemptions on 7/27/22 at 10:25 am, Admin was asked to confirm the four staff on the list. Admin stated one of the staff on the list has since received the vaccination and another staff member, LN H, was not on the list. During an interview on 7/27/22 at 11:25 am, Admin stated that vaccination status was discussed during the initial interview when hiring new staff and was part of the training with new hires. During an interview on 7/27/22 at 11:45 am, Admin stated the facility policy for COVID-19, does not include education to be given to facility staff. During an interview on 7/27/22 at 2:50 pm, Admin stated that unvaccinated staff are given education regarding getting COVID–19 vaccinations and all staff were informed of the new regulations that were coming out and what would need to be done. This education was not documented.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview, and record review, the facility failed to provide physician-ordered services as described in the plan of care when: Three of 10 sampled patients (Patients 1, 3, and 6) had a total of five scheduled visits that were not made, no other visits were made to complete the visit frequency, and the physician was not informed of the missed visits.The ordered services indicated in the plan of care for two of 10 sampled patients (Patients 1, and 9) were not provided. This failure had the potential to prevent patients from receiving necessary care and services, and lead to a loss of well-being and negative clinical outcomes. 3. During a review, of Patient 1's record, she was most recently admitted to this agency for care on 2/22/22, with diagnoses that included Arnold-Chari Spina Bifada (part of the spinal cord is exposed, which can cause serious conditions such as paralysis), Hypertension (high blood pressure) and cystostomy (surgical opening into the urinary bladder). During a review, of Patient’s 1 visit history from certification period 6/22/22 to 8/20/22, two visits had been missed by Skilled Nurse, (SN). Patient 1's record did not contain any evidence that the SN ever attempted to contact the physician about not completing the SN visits on 6/22/22, and 7/4/22 . A communication note indicated, “Missed visit, physician updated, No.” During a concurrent interview, and record review, on 7/26/22 at 2:15 pm, the Administrator (Admin) confirmed that Patient 1's ordered SN services had not been provided, and the physician had not been updated of the change to Plan of Care. 4. During a record review, of Patient 6 was most recently admitted to this agency for care on 6/17/22, with diagnoses that included Hypertension (high blood pressure), Glaucoma (nerve damage to eye when pressure in eye gets too high), visual loss (legally blind), and Atrial-Fibrillation (irregular heartbeat). During a review, of Patient 6’s visit history from start of care to discharge dated 6/17/22 through 7/22/22, two visits had been missed by the home health aide. Patient 6's record did not contain any evidence that home health aide ever attempted to contact the physician, or case manager about not completing these ordered home health visits on 7/1/22, and 7/8/22, with communication note indicated, “Missed visit, physician updated, No.” During a concurrent interview, and record review, on 7/26/22 at 9:10 am, the Admin confirmed that Patient 6's ordered home health aide services had not been provided on 7/1/22, and 7/8/22, and the physician had not been updated of the change to Plan of Care. 5. Patient’s clinical record was reviewed on 6/27/22. Patient 1 was most recently admitted to this agency for care on 2/22/22, with diagnoses that included Arnold-Chari Spina Bifada (part of the spinal cord is exposed, which can cause serious conditions such as paralysis), Hypertension (high blood pressure) and cystostomy (surgical opening into the urinary bladder). Patient 1's plan of care (physician's orders) for certification period through 6/22/22 to 8/20/22, instructed physical therapy to make one visit to “evaluate Patient 1's therapy needs, reassess, and follow up with surgeon on 7/6/22.” During a review of Patient’s 1 visit history from certification period 6/22/22 to 8/20/22, no visits had been made by physical therapy. Patient 1's record did not contain any evidence that physical therapy ever attempted to contact the physician about not completing this ordered evaluation. During a concurrent interview, and record review, on 7/26/22 at 2:15 pm, the Admin confirmed that Patient 1’s ordered physical therapy services had not been provided, and the physician had not been updated of the change to Plan of Care signed on 6/28/22. The agency's policy titled, “Evaluating the Plan of Care/Service Plan," dated 4/02/21, was reviewed and indicated that a written plan of care shall be established for each patient whose care requires medical orders and that the staff will follow this plan of care. The (admin) will ensure processes are in place for ongoing interdisciplinary assessment of the patient and on going needs to ensure the appropriateness of on-going home care/service. 2. A review of the medical record for Patient 9, indicated she was admitted to the facility with diagnoses that included a pressure injury (an injury to the skin and underlying tissue), Alzheimer’s Disease, and palliative care (care for a serious illness). A review of the Plan of Care (POC) for patient 9 indicated that a Medical Social Worker (MSW) was ordered on 6/15/22. The order was for one visit for one week. It was to evaluate the need for any support or community resources. This order for the MSW to see the patient was signed by the Medical Doctor (MD) on 6/27/22. A review of Patient 9’s electronic record did not show any visits had been completed by the MSW. During an interview, on 7/26/22 at 4:09 pm, Administrator (Admin) verified that the MSW did not see the patient, and missed the visit. During an interview, on 7/27/22 at 9:30 am, Admin stated she had spoken to Licensed Nurse (LN) H, who had placed the order for the MSW. LN H stated that there was no need for a MSW, and in fact this order was done in error. Admin stated that LN H made a note in the chart on 7/27/22, to indicate that, and she had informed the MD. Findings: 1. A review of a facility document titled “Developing a Plan to Meet Patient/Client Needs – continued; When Orders for Care/Service Are Required” dated 4/2/21, indicated that patient care must be in accordance with a physician order. A review of a facility document titled “Variances from the Plan of Care/Service Plan” dated 4/2/21, indicated that missed visits must be documented in the clinical record. A review of the clinical record indicated that Patient 3 was admitted on 11/6/21 and had diagnoses of diabetes with a foot wound, dementia, and lung disease, and was to receive visits every week from skilled nursing, and twice a week from the Home Health Aide (HHA). A review of the clinical record indicated that Patient 3 received only one HHA visit during the week of 7/9 – 7/15/22. There was no note in the clinical record documenting a missed visit or physician notification. During an interview and record review on 7/25/22 at 3:30 pm, Licensed Nurse (LN) A confirmed that the HHA had made only one visit to Patient 3 during the week of 7/9 – 7/15/22. During an interview and record review on 7/26/22 at 4:05 pm, HHA confirmed that the visit that should have been made on 7/15/22 to Patient 3 had been missed. HHA confirmed that the missed visit should have been documented in the clinical record. During an interview and record review, the Administrator (Admin) stated that missed visits should be documented on a Missed Visit note in the clinical record. Admin confirmed that missed visits and physician notification were not documented for Patient 3.