Every finding on record at Jar-Cv Enterprises, Inc.

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Recertification surveys. The survey team entered the Home Health Agency (HHA) on 1/7/25 at 1230 hours. The home health agency identified the census as 45. The survey sample size was 7. GLOSSARY AND DEFINITIONS: HHA: Home Health Agency LVN: Licensed Vocational Nurse P&P: Policy and Procedure

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan consistently included strategies for addressing emergency events identified by the risk assessment, creating the potential risk of not providing the necessary care and services to the patients during an emergency event. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/13/25. Documentation showed the HHA had priority levels related to potential emergencies. Documentation showed the scores of eight to 14 points required minimal to moderate attention for additional planning and preparation; and the scores of 15 to 27 points required immediate attention for additional planning and preparation. The 4th Quarter Hazard Vulnerability Analysis Documentation dated 10/23/24, showed the HHA had identified the following as potential emergencies with the corresponding scores: -Drought: 8 -Earthquake: 18 -Epidemic:12 -Flashflood:12 -Wildfires: 12 -Structural damage: 8 -Disease:8 -Public Shooting:18 Further review of the emergency preparedness program documents showed strategies for fire and earthquake. However, there was no documented evidence of the strategies developed to address other identified events like drought and public shooting. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness agency P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This failure created the risk of not effectively utilizing the available personnel during an emergency. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/13/25. The emergency preparedness program did not address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the communication plan included the contact information for the entities providing services under arrangement and patients' physician, creating the risk of not able to contact or request for assistance during the emergency events. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/13/25. There was no documented evidence the communication plan included the contact information for some of the entities providing services under arrangement and the patients' physician. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency communication plan included a primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies, creating the risk of not able to contact or request for assistance in the emergency events. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/13/25. The communication plan failed to include primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included a method for sharing the information and medical documentation for the patients under the HHA's care, as necessary, with other health providers to maintain the continuity of care. This failure created the risk of not providing the necessary care and services to the patients during the emergency events. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/13/25. The emergency preparedness communication plan did not include a method for sharing the information and medical documentation for the patients under the HHA's care, as necessary, with other health providers to maintain the continuity of care. On 1/14/25 at 1100 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included a means of providing information about the HHA's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, Incident Command Center, or designee. This failure posed the risk of not providing quality care to the patients during the emergency events. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/13/25. However, the emergency preparedness communication plan did not include a means of providing information about the HHA's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, Incident Command Center, or designee. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent Recertification and Emergency Preparedness Surveys. The survey team entered the home health agency on 1/7/25 at 1230 hours. The home health agency identified the census as 45. The survey sample size was 7. GLOSSARY AND DEFINITIONS: ALF: Assisted Living Facility BP: Blood Pressure bpm: beats per minute BID: two times a day C.Difficile: bacterium that causes an infection of the colon, the longest part of the large intestine CHHA: Certified Home Health Aide cm: centimeter(s) Covid 19: an infectious disease caused by the SARS-CoV-2 DME: Durable Medical Equipment DPCS: Director of Patient Care Services EENT: eyes, ears, nose, throat EMR: electronic medical record ER: extended release gm: gram(s) H: hour HHA: Home Health Agency HR: Human Resources HS: at bedtime LVN: Licensed Vocational Nurse mcg: microgram(s) mg: milligram(s) mmHg: milliliter(s) of mercury OASIS: Outcome and Assessment Information Set Oxygen saturation: the percentage of oxygen in a person's blood PCG: Primary Caregiver PIP: Performance Improvement Project P&P: Policy and Procedure PO: By mouth POC: Plan of Care port-a-catheter: device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or drugs such as chemotherapy and antibiotics PRN: As Needed PT: Physical Therapy/Therapist PTA: Physical Therapy Assistant Q: Every QA: Quality Assurance QAPI: Quality Assessment and Performance Improvement QD: Daily RN: Registered Nurse SBP: Systolic Blood Pressure (the pressure in the arteries when the heart beats. It's the top number in a blood pressure reading. sepsis: body's extreme response to an infection SN: Skilled Nursing/Nurse SOB: shortness of breath SOC: Start of Care Stage 1 Pressure Injury: non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Stage 2 pressure injury: partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Unstageable Pressure Injury: obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. UTI: Urinary Tract Infection W: Week

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets, creating the risk of not reporting and coordinating the patient care assessments timely for the patients receiving care and services at the agency. Findings: Review of the OASIS validation reports from 6/2024 to 1/2025 was initiated on 1/13/25, and showed the following: The agency's OASIS Agency Final Validation reports from 06/2024, showed there were three OASIS data sets submitted more than 30 days from the assessment completion date. The agency's OASIS Agency Final Validation reports from 07/2024, showed there were five OASIS data sets submitted more than 30 days from the assessment completion date. The agency's OASIS Agency Final Validation reports from 09/2024, showed there were two OASIS data sets submitted more than 30 days from the assessment completion date. The agency's OASIS Agency Final Validation reports from 10/2024, showed there were three OASIS data sets submitted more than 30 days from the assessment completion date. The agency's OASIS Agency Final Validation reports from 11/2024, showed there was one OASIS data set submitted more than 30 days from the assessment completion date. On 1/14/25 at 1156 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure Patient A's grievance was investigated as per the agency's P&P. This failure had the potential for not resolving the patient's complaint or grievance. Findings: The agency's P&P titled Complaint Resolution (undated) showed the agency will investigate complaints made by a patient, including but not limited to treatment or care that is furnished or furnished inconsistently. The designated individual who will respond to and takes action to resolve complaints is the Director of Clinical Services. The action includes investigative measures based on the nature of the complaints. Review of the agency's Grievance Log for the year 2023 showed a documentation of a complaint from Patient A. The date of incident was 7/29/23. The details of the complaint were related to the agency's inability to provide PT services. Review of the agency's Grievance Log showed an electronic mail dated 7/18/23, between the agency staff and PT providers related to PT visits. However, review of the agency's Grievance Log failed to show documented evidence of an investigation conducted related to PT services. On 1/13/25 at 1423 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator was asked if they completed an investigation report. The Administrator replied, no. The Administrator was also asked if they interviewed the PT as part of the investigation. The Administrator replied, no. The Administrator was informed and acknowledged the findings.

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 agency failed to provide a complaint resolution to Patient A's complaint as per agency's P&P. This failure had the potential of not addressing the patient's needs or grievance. Findings: The agency's P&P titled Complaint Resolution (undated) showed to provide for a prompt and equitable resolution of complaints by patients. The purpose was to provide a mechanism for use by the patient to assure response, and if possible resolution of a complaint in a timely manner. The procedure includes to document the resolution of the complaint. The designated individual who will respond to and take action to resolve complaints is the Director of Clinical Services. The action includes complaint resolution is achieved in accordance with the established time frames. Review of the agency's Grievance Log for the year 2023 showed a documentation of a complaint from Patient A. The date of incident was 7/29/23. The details of the complaint were related to the agency's inability to provide PT services. Review of the Grievance Log showed an acknowledgement letter dated 8/2/23, was sent to the complainant. However, review of the Grievance Log failed to show a resolution of the complaint as per the agency's P&P. In addition, review of the log failed to show a resolution letter was sent to the complainant. On 1/13/25 at 1423 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator was asked if they have a timeline to send a resolution letter. The Administrator replied as soon as possible when the investigation was completed, they have to send a resolution letter. The Administrator was informed and acknowledged the findings. Cross ref. G-478

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the SOC date for two of seven sampled patients (Patients 3 and 7), creating the risk of not identifying and addressing the care needs timely for these patients. 2. Review of Patient 7's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The start of care assessment dated 10/29/24, showed the patient had Stage 2 left heel pressure injury. * However, there was no documented evidence the SN assessed the wound odor and the appearance of the wound bed. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for hospice services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The OASIS Start of Care dated 9/11/24, showed the RN had performed the initial comprehensive assessment. However, there was no documented evidenced the RN had assessed the patients height and weight as the section was left blank. In addition, the section for the RN printed name, signature and date was left blank. On 1/14/25 at 1227 hours an interview and concurrent clinical record review was conducted with the LVN Care Coordinator, Administrator and HR Manager. They were informed and acknowledged the findings.

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 ensure the review of the medications included all of the patient's current medications to identify any potential adverse effects and drug reactions for three of seven sampled patients (Patients 3, 4, and 5). This posed the risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. 3. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. a. The Medication Profile for the certification period from 11/20/24 to 1/18/25, showed the patient's medication included losartan (antihypertensive) 50 mg one tablet PO once daily, amlodipine (antihypertensive) 2.5 mg PO one tablet PO one daily, Eliquis (anticoagulant) 5 mg one tablet PO Q 12 hours, pantoprazole (used to treat GERD) 40 mg one tablet PO once daily, Celecoxib (non-steroidal anti-inflammatory drug)100 mg one tablet PO PRN Q six hours for moderate pain, gabapentin (anticonvulsant) 100 mg one tablet PO once daily, alendronate (used to treat osteoporosis), loratadine (antihistamine) 10 mg one tablet PO once daily, and calcium carbonate (supplement) 500 mg once daily, Oxycodone (opioid analgesic) 5 mg one tablet PO Q four hours PRN for severe pain, tramadol (opioid analgesic) 50 mg PO Q four hours PRN for 7-10 pain rate (0= no pain 10 worst pain). Documentation showed the medications listed above have been reviewed for potential adverse effects and drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy. According to Celecoxib’s prescribing information, the significant drug interaction between Celecoxib and anticoagulants such as warfarin have a synergistic effect on bleeding. The concomitant use of Celecoxib and anticoagulants have an increased risk of serious bleeding compared to the use of either drug alone. * However, there was no documented evidence the HHA had identified the potential drug interaction between Celecoxib and Eliquis. b. The SN note dated 12/13/24, showed during the home health visit the patient was educated on the chemotherapy regimen with 5-fluorouracil (medication to treat cancer) and care of the port- a catheter. * However, the patient’s chemotherapy regimen with 5-fluorouracil as per the SN note dated 12/13/24 was not included in the medication profile. c. A joint home visit with RN 1 was conducted on 1/9/25 at 1000 hours, to Patient 4's home. Review of the patient's medications with the RN 1 showed the following: -Patient 4 was on Celecoxib 200 mg one capsule a day for pain. -Patient 4 was on gabapentin 100 mg one tablet BID, instead of once daily. -Patient 4 was on calcium carbonate 500 mg twice a day instead of once daily -Patient 4 stated Oxycodone was stopped in September and was not taking tramadol due to upset stomach. The patient stated tramadol was taken long time ago. The patient stated new medications included vitamin D3 (supplement) 125 mcg one tablet once daily and ferrous sulfate (supplement) 325 mg one tablet PO once daily,. * However, the patient's medication profile was not updated. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. The agency's P&P titled Medication Profile revised 3/18, showed all prescribed medications, over the counter (OTC) medications and home remedies will be documented on the medication profile. The nurse or therapist will add all new /changed medication(s) to the medication profile. The medication profile will be reviewed every home visit and updated as changes occur. 1. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The Medication Profile for the certification period from 11/10/24 to 1/8/25, showed the patient's medications included lisinopril (ACE inhibitors) 5 mg tablet one tablet PO QD, Montelukast (anti -asthma) 10 mg one tablet PO QD, omeprazole (acid reflux), buspirone (anti- anxiety) 10 mg tablet one tablet PO QD, quetiapine (atypical antipsychotic) 50 mg tablet one tablet PO BID, escitalopram (SSRI's) 10 mg tablet one tablet PO QD, memantine (memory loss), Vitamin D3 (supplement) 25 mcg capsule one capsule PO QD, docusate sodium (laxative) one capsule PO QD and Senna (laxative) 8.6 mg tablet one tablet PO BID. A joint home visit with CHHA was conducted on 1/8/25 at 1330 hours, to Patient 3's home. Review of the patient's medications with the PCG and the CHHA showed the patient was on Vitamin D3 (supplement) 5000 mcg capsule one capsule PO QD instead of 25 mcg as listed on the medication profile. In addition, patient was taking Severe Cold and Flu (Acetaminophen 325 mg) two tablets in the morning and PRN which was not listed on the medication profile. Moreover, the PCG reported the patient was not taking lisinopril 5 mg one tablet PO QD as instructed by the patients pulmonologist. The PCG was asked as to the last time the patient took the medication. The PCG replied, a month ago. The PCG also reported the patient was not taking Montelukast 10 mg one tablet PO QD. On 1/8/25 at 1448, the findings were shared with the CHHA . On 1/14/25 at 1239 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The Medication Profile for the certification period from 1/3/25 to 3/3/25, showed the patient medication list included the new and old medications. The medications included carbidopa 25 mg levodopa 100 mg (anti- Parkinson) tablet two tablets PO four times a day, tramadol (opioid) 50 mg tablet one tablet Q8H PRN for severe pain related to Parkinson's, Zofran (anti -emetic) 4 mg tablet one tablet Q6H PRN for nausea, Colace (laxative) 100 mg capsule one capsule PO QD and melatonin (supplement) 10 mg one table PO QHS and triamcinolone acetonide (topical corticosteroids) 0.1 mg topical cream apply to affected area topically BID. A joint home visit with PTA was conducted on 1/9/25 at 0945 hours, to Patient 5's home. Review of the patient's medications with the PCG and the PTA showed the patient medication profile showed the following list: The list of the new medications included the following: -Flomax (selective alpha adrenergic blocking agent) 0.4 mg one capsule one capsule PO QD, -Cyanocobalamin -Vitamin B 12 ER (supplement) 1000 mcg tablet one tablet PO QD, -Multivitamin with minerals (supplement) one tablet PO QD, -Propranolol (beta adrenergic blocking agents) 10 mg one tablet PO BID. Hold for SBP less than 110 or Pulse rate less than 60 and -Vitamin D3 (supplement) 50 mcg (2,000 unit) one tablet PO QD. However, these new medications were not listed on the patient medication list in the facility. In addition, the medication profile showed the list of the old medications. The medications included the following: -lisinopril (antihypertensive) 10 mg one tablet PO QD, -albuterol sulfate HFA (bronchodilators) 90 mcg/actuation aerosol inhaler 2 puffs into lungs every 4 hours PRN for shortness of breath, -sertraline (anti- depressant) 25 mg tablet one tablet PO QHS and -Ativan (anti-anxiety) 1 mg one tablet PO QHS. However, these list of old medications were not listed on the patients medication list in the facility. On 1/9/25 at 1053 hours, an interview and concurrent clinical record review was conducted with the ALF Clinical Director and the PTA. The ALF Clinical Director was asked for the list of the patient medication profile. The ALF Clinical Director provided the current medication list. They verified the HHA medication profile does not match with the facility's current list. The PTA was informed and acknowledged the finding. On 1/14/25 at 1117 hours, the findings were shared with the DPCS.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for three of seven sampled patients (Patients 1, 3, and 5), creating the increased risk of not addressing the care needs for these patients. Findings: 1.Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. a. Review of the Recertification OASIS dated 3/29/24, showed the RN had performed a comprehensive assessment. The assessment included a section of Wound/Lesion which showed the patient had an unstageable pressure injury to the left heel measuring 1.5 cm (length) x1.5 cm (width) and without odor or drainage. However, the wound assessment was incomplete as part of the comprehensive assessment. b. Review of the Discharge OASIS dated 4/4/24, showed the RN had performed a comprehensive assessment. The assessment included a section of Wound/Lesion which showed the patient had an unstageable pressure injury to the left heel measuring 1.5 cm (length) x1.5 cm (width), no odor but with small thick serosanguinous drainage. However, the wound assessment was incomplete as part of the comprehensive assessment. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. Cross reference to G984. 2. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the certification periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The assessment included a section for the patient's height and weight. However, the section for height and weight were left blank. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 3. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the certification periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. Review of the Recertification OASIS dated 1/2/25, showed the RN had performed the comprehensive assessment. The assessment included the administrative information, COVID-19 screening, emergency preparedness, emergency contact information, functional status and musculoskeletal status. However, the multiple sections in the comprehensive assessments were left blank. On 1/10/25 at 1400 hours, an interview and concurrent clinical record review was conducted with the HR Manager. The HR Manager was asked to provide a copy of the recertification assessment. The HR Manager replied, the assessment was not completed. On 1/14/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked as to the timeline for the completion of the recertification assessment. The DPCS replied within 48 hours from the date of the visit. The DPCS was informed and acknowledged the findings.

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 interview and record review, the agency failed to ensure the POCs included specific information related to medications, nutritional requirement, DME and supplies for four of seven sampled patients (Patients 4, 5, 7, and 8) creating the risk of not addressing the care needs for these patients. 3. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. * However, the POC failed to include DME/supplies and nutritional requirements. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The POC, for the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25, cited SN visits 2W2 and 1W7 to perform comprehensive observation and assessment of all body. The POC included the following pain medications: acetaminophen (analgesic) 325 mg two tablets PO Q six hours for pain, diclofenac sodium (non-steroidal anti-inflammatory drug) gel 1% apply 4 gm topically Q six hours PRN for pain, and Percocet (opioid analgesic) 5-325 mg one tablet PO Q four hours PRN for pain. * However, there was no documented evidence which pain medication was to be given first. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 8's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed SN to perform and assess vital signs to include oxygen saturation, comprehensive observation and assessment of all body systems with emphasis to include respiratory every visit. POC includes an instruction to keep oxygen away from any open flame. However, the POC did not include specific instructions as to the level of oxygen the patient can use to address respiratory issues. In addition, the POC failed to include the DME and supplies as the section was left blank. Moreover, the POC also includes an instruction related to managing hyperlipidemia. However, the POC failed to include the patient nutritional requirement as the section was left blank. On 1/14/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis to include integumentary every visit. The POC includes the list of DME and supplies. The supplies included Betamethasone cream. Review of the SN notes on the following dates showed: -on 10/15/24 under the section of narrative notes, showed the SN had applied Betamethasone cream on the right arm. -on 11/8/24 under the section of narrative notes, showed the SN had applied Betamethasone cream on the arm. -on 11/14/24 under the section of narrative notes, showed the SN had applied Betamethasone 0.005 % cream to the affected area BID for itching. -on 11/21/24 under the section of narrative notes, showed the SN had applied Betamethasone cream on the affected area for itchiness. However, the POC failed to include specific instructions for the use of betamethasone cream. On 1/14/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC, for the certification period from 1/3/25 to 3/3/25 cited SN visits 1W9. The POC showed SN to continue to monitor, observe vital signs, neurological status, musculoskeletal status, cardiopulmonary/respiratory, circulatory status and pain level/comfort. However, the POC did not include nutritional requirement, DME and supplies as the sections were left blank. On 1/14/25 at 1110 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the treatment was provided only as ordered by the patient's physician for three of the seven sampled patients (Patients 1, 3 and 6), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1.Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 1/30/24 to 3/29/24, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis to include integumentary system every visit. Review of the SN notes dated 2/9/24, on the section of narrative notes, showed the patient was assessed to have stage 1 pressure injury to the left heel. The SN performed wound treatment with calmoseptine (moisture barrier) and foam dressing. However, review of the closed clinical record failed to show a physician's order for the wound treatment. In addition, review of the SN visit notes dated 2/16, 2/21, 2/28 and 3/9/24, on the section of wound type, showed the patient was assessed to have a stage 2 pressure injury. Further review of the SN notes, on the section of the narrative, showed the location of the pressure injury was to the left heel. The SN had performed wound dressing and treatment. The treatment includes clean with normal saline, pat dry and applied xeroform (petrolatum-based fine mesh gauze containing 3% bismuth tribromophenate), change dressing daily or as needed. However, review of the closed clinical record failed to show documented evidence of a physician's order for the treatment of the patient's stage 2 pressure injury to the left heel. Cross reference to G602 On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 8's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis on respiratory every visit. Review of the SN visit note dated 12/12/24, showed the SN had performed respiratory system assessment. The patient was on oxygen at 3 liters via nasal cannula and was assessed to have dry cough; with wheeze and SOB on moderate exertion of less than 20 feet. Further review of the SN visit notes dated 12/20, 12/23/24 and 1/4/25, showed the patient was on oxygen at 3 liters via nasal cannula and was assessed to have dry cough and with wheeze. However, review of the clinical record failed to show documented evidence of a physician's order for the use of oxygen at 3 liters via nasal cannula. On 1/14/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if they needed to have a physician's order for the use of oxygen. The DPCS replied yes. The DPCS was also asked if there was an order for the oxygen use. The DPCS replied it was not on the plan of care or supplemental order. The DPCS was informed and acknowledged the findings. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis to include respiratory and integumentary every visit. The POC included the list of DME and supplies. The list included oxygen concentrator. Review of the SN visit notes dated 10/15, 10/24, 10/30, 11/8, 11/14, 11/21, and 11/29/24, showed the SN had performed respiratory system assessment. The patient was on oxygen at 3 liters via nasal cannula and was assessed to have dry cough and with wheeze. However, review of the clinical record failed to show documented evidence of a physician's order for the use of oxygen at 3 liters via nasal cannula. On 1/14/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 3. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the certification periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC, for the certification period from 11/10/24 to 1/8/25, cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. a. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment, on the section of wound care, showed the patient was identified to have a blister on the right buttock with the following treatment: cleansed with normal saline, pat dry, and apply calmoseptine (moisture barrier). Further review of the comprehensive assessment showed the blister on the right buttocks measured 1.5 cm (length) x 1.5 cm (width) with the following treatment: cleansed with normal saline, pat dry, and covered with Mepilex (a foam dressing that absorbs exudate and maintains a moist wound environment) dressing. However, review of the clinical record failed to show documented evidence of a physician's order for wound treatment to the patient's right buttock blister. b. Review of the SN notes dated 12/19 and 12/26/24. on the section of narrative, showed the SN had applied diclofenac (nonsteroidal anti-inflammatory drug) gel to the patient's bilateral knees to relived pain. However, review of the clinical record failed to show documented evidence of the physician's order for the use of diclofenac gel for pain. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was a physician's order for wound treatment and diclofenac gel. The DPCS replied there was no physician's order. The DPCS was informed and acknowledged the findings.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to revise and update the POC for three of seven sampled patients (Patients 3, 4, and 8), creating the risk for not providing the necessary care and services to meet the care needs for these patients. 3. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems. The PT note dated 11/20/24, showed the PT conducted a visit. The PT note dated 11/25/24, showed the patient was discharged. * However, there was no documented evidence the POC during the certification period from 11/20/24 to 1/18/25, was revised to include PT services. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 8's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 12/6/24, showed the patient was assessed to have a dermatitis to the bilateral arms However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the assessment and treatment dermatitis should be address on the POC. The DPCS replied, it's not and should have been address on the POC. The DPCS was informed and acknowledged the finding. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 10/9/24, showed the patient was assessed to have a dermatitis to the bilateral arms However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25 cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment on the section of wound care showed the patient was identified to have a blister on the right buttock. Cleansed with NS, pat dry, apply Calmoseptine. Further review of the comprehensive assessment showed the blister on the right buttocks measures 1.5 x 1.5 cm. Cleansed with NS, pat dry and covered by Mepilex dressing. However, the RN failed to update/ revised the POC to reflect the wound assessment and treatment for the identified blister on the right buttock. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the wound assessment and treatment needed to be included in the POC. The DPCS replied, it should be. The DPCS was informed and acknowledged the findings. - Cross ref. G-580 Findings: 1.Review of Patient 8's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 12/6/24, showed the patient was assessed to have a dermatitis to the bilateral arms. However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the assessment and treatment dermatitis should be address on the POC. The DPCS replied, it's not and should have been address on the POC. The DPCS was informed and acknowledged the finding. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 10/9/24, showed the patient was assessed to have a dermatitis to the bilateral arms However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25 cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment on the section of wound care showed the patient was identified to have a blister on the right buttock. Cleansed with NS, pat dry, apply Calmoseptine. Further review of the comprehensive assessment showed the blister on the right buttocks measures 1.5 x 1.5 cm. Cleansed with NS, pat dry and covered by Mepilex dressing. However, the RN failed to update/ revised the POC to reflect the wound assessment and treatment for the identified blister on the right buttock. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the wound assessment and treatment needed to be included in the POC. The DPCS replied, it should be. The DPCS was informed and acknowledged the findings. - Cross ref. G-580 3. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems. The PT note dated 11/20/24, showed the PT conducted a visit. The PT note dated 11/25/24, showed the patient was discharged. * However, there was no documented evidence the POC during the certification period from 11/20/24 to 1/18/25, was revised to include PT services. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure effective communication with the patient's physician for four of seven sampled patients (Patients 1, 3, 5, and 8), creating the risk of not providing necessary care and services to these patients. Findings: The agency's P&P titled Coordination of Patient Care revised 3/2019 showed the agency must assure communication with all physicians involved in the plan of care. Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. 1. Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. Review of the SN visit notes dated 2/16, 2/21, 2/28, and 3/9/24, on the section of wound type, showed the patient was assessed to have a stage 2 pressure injury. Further review of the SN notes, on the section of the narrative, showed the location of the pressure injury was on the left heel. The SN had performed wound dressing and treatment. However, review of the closed clinical record failed to show documented evidence the physician was notified of the patient's stage 2 pressure injury. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 8's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. The POC, for the certification period from 10/11/24 to 12/9/24, cited PT evaluation and treatment. The PT visits were cited 2W3. Review of the PT Clinical notes dated 10/30/24, showed a PT discharge. Review of the PT Communication Notes dated 10/30/24, showed a summary of care provided, physician's order to discharge from PT and to follow up with physician, and the staff name, signature and date. However, the discharge order did not include the physician's name, signature and date. On 1/14/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if they needed to notify the patient's physician of the PT discharge. The DPCS replied there was no notification. The DPCS was also asked if they needed to get a discharge order. The DPCS reviewed the clinical record and replied yes, but it was not signed. The DPCS was informed and acknowledged the findings. 3. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25, cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all the body systems. The POC also included to assess the pain, implement pain relief measures, evaluate its effectiveness every visit, and notify the physician for pain greater than 7 on a pain scale of 0 to 10 (0= no pain and 10 = worst pain), interfering with movement not relieved by pain medication/rest. Review of the SN notes on the following dates showed the patient was assessed to have pain using the pain scale of 0 to 10, zero meaning no pain and 10 meaning worst pain): -On 11/14/24 - 6/10, -On 11/21, 11/30, and 12/7/24 - 7/10, -On 12/12/24 - 9/10, -On12/19/24 - 8/10 and -On 12/26/24- 10/10. The pain was located at the bilateral knees described as achy and intermittent. The treatment was rest and gel. However, review of the clinical record failed to show documented evidence the patient's complaints of pain greater than 7 on a pain scale of 0 to 10 was communicated to the patient's physician. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. Cross ref. G-710 4. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for home health services during the certification periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The Recertification OASIS dated 11/2/24, showed the patient was requesting a continuation for PT. The patient was assessed to have generalized weakness. However, review of the clinical record failed to show documented evidence the request for PT services was coordinated with the physician. Further, review of the SN visit notes dated 11/5, 11/15, 11/22, 11/25, 12/5, 12/12, 12/19, and 12/23/24, showed the SN had performed the motor/musculoskeletal system assessment. The patient was assessed to have a decreased in mobility and had weakness with assistive device. However, review of the clinical record failed to show documented evidence of the physician was notified of the decrease mobility as identified on the assessment. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the need for PT was coordinated with the physician. The DPCS replied there was no documentation at this time, and she cannot find the notes in the system. The DPCS was informed and acknowledged the findings.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services provided to the patient was coordinated for one of seven sampled patients (Patient 4), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all the body systems. The Communication Note dated 12/6/24, showed the LVN reported the patient was complaining of difficulty in sleeping. Documentation showed the physician was notified. However, there was no documented evidence the HHA had coordinated/followed up what the physician’s response was after the physician was notified of patient’s difficulty in sleeping. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide a written instructions outlining the visit schedule for one of seven sampled patients (Patients 4). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all the body systems. A joint home visit with RN 1 was conducted on 1/9/25 at 1000 hours, to Patient 4's home. Review of the patient’s home folder was conducted with RN 1. However, there was no documented evidence of written instructions outlining the SN visit schedules. On 1/14/25 at 1120 hours, an interview and concurrent clinical record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the clinical managers contact information were provided to three of the seven sampled patients (Patients 3, 4 and 5), creating the risk of substandard care provided to these patients as the contact information were not available. 3. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. A joint home visit with RN 1 was conducted on 1/9/25 at 1000 hours, to Patient 4's home. Review of the patient's home folder was conducted with RN 1. * However, the contact information of the agency's clinical manager was not available in the patients home folder. On 1/14/25 at 1120 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. The agency's P&P titled Coordination of Patient Care revised 3/19, showed the agency will coordinate care with the patient by providing a copy of written instructions outlining the name and contact information of the agency's Director of Clinical Services. 1. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for hospice services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC, for the certification period from 11/10/24 to 1/8/25, cited CHHA 1W4 and reassess. A joint home visit with CHHA was conducted on 1/8/25 at 1330 hours, to Patient 3's home. Review of the agency's admission packet was conducted with the CHHA and the PCG. The agency's admission packet showed the names of the agency's visiting staff. However, review of the patient's admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA's clinical manager. On 1/8/25 at 1448 hours, an interview and concurrent document review was conducted with the CHHA and the PCG. They were asked if the contact information of the agency's clinical manager was available in the home folder. The CHHA reviewed the home folder and replied no, I didn't see it. On 1/14/25 at 1239 hours, the DPCS was informed of the finding. 2. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC, for the certification period from 1/3/25 to 3/3/25, cited PT evaluation and treatment. A joint home visit with PTA was conducted on 1/9/25 at 0945 hours, to Patient 5's home. Review of the agency's admission packet was conducted with the PTA. The agency's admission packet showed the names of the agency's visiting staff. However, review of the patient's admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA's clinical manager. On 1/9/25 at 1039 hours, an interview and concurrent document review was conducted with the PTA and the PCG. They were asked if the contact information of the agency's clinical manager was available in the home folder. The PTA reviewed the home folder and replied no, I don't see it here. On 1/14/25 at 1117 hours, the DPCS was informed of the finding.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the hospice failed to document the reasons for conducting or selecting the PIP for the 2023 and 2024 and consistently measure the progress achieved on these projects. This created the risk of not identifying the opportunity for improvement for care and services provided to the agency's patients. Findings: The HHA's P&P titled Performance Improvement Projects revised 03/2018, showed the agency will conduct performance improvement projects. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the agency’s services and operations. The agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. The agency should have one performance improvement project either in development, ongoing, or completed each calendar year. The agency decides, based on the QAPI program activities and data, what projects indicated and the priority of the projects. On 1/13/24 at 1413 hours, an interview was conducted with the Administrator. She stated the QAPI members meet quarterly. She stated the QAPI meeting included discussion of infection control program, patient satisfaction survey, fall reduction, record review, sentinel events, grievance, contractor audits, and any input from the case manager. She stated PIPs were also discussed during the meeting. She stated both 2023 and 2024 PIPs were still ongoing. Review of the QAPI meeting minutes from the 1st, 2nd, 3rd, and 4th quarters of 2023 and from the 1st, 2nd, and 3rd quarters of 2024, showed the HHA had conducted the quarterly QAPI meeting. Review of the Performance Improvement Project 2023 (undated) showed the program area was the “Adequacy of Documentation- need to improve documentation on OASIS to show patient eligibility of home health.” Documentation showed the problem included nursing and therapy initial assessment must be documented properly and should show the need for home heath in their OASIS report; and nursing and therapy were still not well versed with the new OASIS-E program. Documentation showed data source included QA record review of OASIS. Documentation included the list of possible solutions/actions taken and the expected outcome. Review of the Performance Improvement Project 2024 (undated) showed the program area was the “Adequacy of Documentation- Timeliness of Submission of clinical notes and improvement on documenting clinical notes.” Documentation showed the problem included based on chart audit conducted by the QAPI team, there was 10% tardiness on submission of paperwork, and it is affecting the billing. Documentation included the list of possible solutions/actions taken and the expected outcome. * However, there was no documented evidence of data indicating the HHA had a problem in the area targeted for improvement. There was no documented evidence of the result and progress of the performance improvement project conducted for the years of 2023 and 2024. There was no documented evidence the solutions/actions taken were reevaluated to ensure the effectiveness of implemented plan for improvement. On 1/14/25 at 1224 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement and maintain the agency's infection control program which included surveillance, identification, prevention, control, and investigation of infections. This failure had the potential for spread of infections. Findings: Review of the agency's P&P titled Infection Control Surveillance System: Prioritized Risks Identified revised 3/2018 showed the following: -The agency will implement an infection control surveillance system for patients and staff. The definition of infections is based on the most common infections prevalent to agency’s services that are high volume, frequent infectious complications and have a high potential for prevention by staff and/or have an increased risk for negative patient outcomes. -Written reporting of infections will occur through documentation on the applicable log (patient or employee). -At least quarterly, the Director of Clinical Services and infection control and QAPI Committee will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patient and Employees form. -Problems and/or undesirable trends in infections will be identified, including potential significant agency acquired and/or community acquired infections. If such problems or undesirable trends are identified, the infection control and QAPI Committees will identify ant common factors that could have led to the transmission of the infections(s). -The committees will make recommendations for and implement improvement activities. Review of the infection control documents from the 1st, 2nd, 3rd, and 4th quarters of 2023 and from the 1st, 2nd, and 3rd quarters of 2024, showed the HHA had collected infection control cases for the patients. a. The total number of infection control cases reported in the Infection Control Quarterly Data Aggregation and Analysis was not consistent with the Patient Infection Control Log. For example: The 1st Quarter of 2024 Patient Infection Control Log showed there were nine infection cases. The 1st Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were eight infection cases, which was not consistent. The 2nd Quarter of 2024 Patient Infection Control Log showed there were twelve infection cases. The 2nd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were seven infection cases, which was not consistent. b. The type of infection control cases reported in the Infection Control Quarterly Data Aggregation and Analysis was not consistent with the Patient Infection Control Log. For example: The 3rd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were total of eight infection cases. There was one case of wound infection, four cases of UTI, one case of sepsis, one case of C-difficile, and one case of bone infection. The 3rd Quarter of 2024 Patient Infection Control Log showed there were 10 infection cases. There were three cases of wound infection, one case of ear infection, one case of bone infection, four cases of UTI, and one case of a combination of UTI/sepsis. * However, the number of the type of infection cases was not consistent related to wound, ear, and C-difficile infection. c. There was no documented evidence the agency had analyzed the data, thoroughly investigated for possible causes of infections, and implemented specific actions to minimize infections. For example: The 2nd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there was one case of UTI. The 3rd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were four cases of UTI. The 3rd Quarter of 2024 QAPI under the infection control showed the agency continue to perform the monitoring. Documentation showed for four cases of UTI. The scheduled actions included improve data collection using EMR, improve reporting from PCG and staff, in-service on infection control will be provided to staff, family, patient, geographic served on distinguishing of signs and symptoms of infection, and universal precaution. * However, the agency failed to identify the increase in wound infection cases from the 2nd to the 3rd Quarter of 2024. There was no documented evidence the agency investigated for possible causes of infections. The action plans for the 1st, 2nd, and 3rd Quarter of 2024 QAPI had the same information. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

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 observation, interview, and record review, the agency failed to ensure the patients received care and services as per the written plan of care for four of the seven sampled patients (Patients 1, 3, 4, and 7). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. 3. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. The SN notes dated 11/21, 11/27, 12/4, 12/13, and 12/27/24, showed under the patient’s cardiovascular assessment showed a box was marked as “Other.” * However, there was no documented evidence on what was the SN’s cardiovascular assessment for the patient. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The POC, for the certification period from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25, cited SN visits 2W2 and 1W7. The POC included the following: -SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. -SN to instruct caregiver on "foley" catheter care and for SN to perform catheter change every 30 days or as needed for leakage or dislodgement. a. The SN note dated 11/29/24, showed no documented evidence the assessment for EENT, gastrointestinal, and genitourinary was completed. b. The start of care assessment dated 10/26/24, showed the patient’s last urinary catheter change was on 10/26/24. * However, there was no documented evidence the SN performed catheter change for the month of November, which was more than 30 days as per the POC. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1a. Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 3/20/24 to 5/28/24, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, digestive status and to check oxygen saturation every visit. The POC also includes the patient nutritional requirement was low sodium, no concentrated sweets. * Review of the SN notes dated 4/3, 4/8 and 4/24/24 showed the SN assessed the patients' diet was regular. However, the diet order was low sodium, no concentrated sweets. * Review of the SN notes dated 4/3, 4/8 and 4/24/24, showed the SN had performed gastrointestinal assessment. However, the SN failed to check the patients' last bowel movement as the section was left blank. * Review of the SN notes dated 4/24/24, showed the SN had performed respiratory assessment. However, the SN failed to check the patients' oxygen saturation level as section was left blank. On 1/14/25 at 1208 hours an interview and concurrent closed medical record review was conducted with the DPCS. The DPCS was asked if the patient diet was followed as ordered. The DPCS reviewed the SN visit notes and replied no. The DPCS was also asked if the SN needed to check the patients oxygen saturation and the last bowel movement every visit. The DPCS replied, yes, should be check but none was documented. The DPCS was further asked if the POC was followed. The DPCS replied, not followed. The DPCS was informed and acknowledged the findings. b. The POC, for the certification period from 1/30/24 to 3/29/24, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine and integumentary every visit. The POC showed to instruct patient/caregiver on dietary compliance on low sodium, no concentrated sweets. * Review of the SN notes dated 2/9, 2/16, 2/21, 2/28 and 3/21/24, showed the SN had assessed the patients diet. The diet was documented as regular. However, the order was for low sodium, no concentrated sweets. In addition, review of the SN notes dated 3/9 and 311/24, failed to show the SN had assessed the patients diet as the section was left blank. * Review of the SN notes dated 2/9, on the section of Wound Type, showed the patient was assessed to have stage 1 pressure injury. The location of the pressure injury was to the left heel as documented on the narrative notes. However, the SN failed to assessed the pressure injury stage 1 as ordered on the POC. In addition, review of the SN notes dated 2/16, 2/21, 2/28 and 3/9/24 showed the patient was assessed to have a stage 2 pressure injury. The location of the pressure injury was to the left heel as documented on the narrative notes. However, the SN failed to performed a complete wound assessment for the patients pressure injury stage 2 as ordered on the POC. Cross ref. G-984 * Review of the SN notes dated 2/28/24, showed the SN had performed body system assessment. However, the the SN failed to assessed the patients cardiovascular, respiratory, EENT and Motor/musculoskeletal system as ordered in the POC. On 1/14/25 at 1208 hours an interview and concurrent closed medical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2a. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25 cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. The POC also includes to assess pain scale and implement pain relief measures and evaluate its effectiveness every visit and notify MD for pain scale greater than 7/10, interfering with movement not relieved by pain medication/rest. Review of the SN notes on the following dates showed the patient was assessed to have pain: -On 12/12/24 - 9/10, -On12/19 - 8/10 and -On 12/26- 10/10. The pain was located at the bilateral described as achy and intermittent. The documented treatment was rest and gel. However, review of the clinical record failed to show documented evidenced of the physician was notified of the patients pain as ordered in the POC. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. The POC for the certification period from 9/11/24 to 11/9/24, cited PT evaluation and treatment. Review of Physicians Order dated 9/13/24 showed a visit frequency for 1W1, 2W3,1W1. Review of the PT visits on Week 2 (9/15/24 to 9/21/24) showed the PT visit the patient on 9/17/24 However, the PT visited the patient one time instead of two times as ordered by the physician. In addition, review of the PT visit notes on Week 5 (10/6 to 10/12/24), showed the PT visited the patient on 10/7/23. Review of the Physicians Order dated 10/11/24, showed an order for a change in PT visit frequency. The order was cited for 2W2, 1W1. However, there was no documented evidenced of the PT visited the patient on 10/12/24 for as ordered by the physician. c. Review of the Admission Order dated 9/11/24, showed the diet order was no added salt, high fiber, high protein, low cholesterol and low fat. However, review of the POC for the certification period 9/11/24 to 11/9/24, showed the diet order was regular which was inconsistent with the physicians order. On 1/14/25 at 1227 hours, an interview and concurrent clinical record review was conducted with the LVN Care Coordinator, HR Manager and the Administrator. They were informed and acknowledged the findings.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and or caregiver was provided an education related to disease process and management of diabetes, medication and Port-a catheter care as per the plan of care for two of the seven sampled patients (Patients1 and 4), creating the risk of not providing the necessary care and services these patients. 3. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The recertification reassessment dated 11/16/24, showed not applicable under infusion assessment. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. The SN note dated 12/13/24, showed during the home health visit the patient was educated on the chemotherapy regimen with 5-fluorouracil (medication to treat cancer) and care of the port- a catheter. There was no documented evidence the POC included education on the care of the port-a catheter and the patient’s medication included 5-fluorouracil. * However, the POC did not include education related to port-a-catheter and 5-fluorouracil. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 3/20/24 to 5/28/24, cited SN visits 1W9. The POC includes SN to teach disease processes and management, preventive measures, signs and symptoms of complication/exacerbations with emphasis on Type 2 DM. SN to instruct on managing hypoglycemia through meals, help prevent hypoglycemic reactions and maintain overall blood glucose control. Review of the SN visit notes dated 4/3, 4/8, 4/17 and 4/24/24 on the section of Skilled Teaching/ Instructions showed a check mark on skilled observation and assessment, teach disease process related to and teach prevention of disease exacerbation and hospitalization. However, on the section of teach diabetic care, hypoglycemia and hyperglycemia was left blank. On 1/14/25 at 1208 hours an interview and concurrent closed medical record review was conducted with the DPCS. The DPCS was asked if diabetic teaching or instructions was provided to the patient as ordered in the POC. The DPCS reviewed the SN visit notes and replied no. The DPCS was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for four of 7 sampled patients (Patients 1, 4, 5, and 7), creating the increased risk of substandard healthcare outcomes to these patients. 3. The P&P titled Timely Submission of Documents revised date 2017, showed itineraries will all visit reports attached must be submitted the next scheduled work day, not exceeding three business days. All patient visit reports from contract personnel must be submitted within three business days from the date of the visit. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. The electronic clinical record showed the SN conducted a visit on 1/1/24. * However, there was no documented evidence the SN completed the note as of 1/13/24. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The POC, for the certification period from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25, cited SN visits 2W2 and 1W7. The POC included SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. The POC included SN to instruct caregiver on "foley" catheter care and for SN to perform catheter change every 30 days or as needed for leakage or dislodgement. a. The start of care assessment dated 10/29/24, showed under the wound section the patient had Stage 2 left heel pressure injury. Documentation showed under narrative section of the form showed the patient had left heel diabetic ulcer. The Wound Care Work Sheet dated 10/29/24, showed the patient had Stage 2 left heel pressure injury. * However, the type of wound documented was not consistent on 10/29/24. b. The SN note dated 12/3, 12/7, 12/10, 12/17, 12/21, and 12/31/24, showed “See Wound sheet assessment and treatment.” However, there was no documented evidence the SN completed the wound sheet assessment and treatment. c. The start of care assessment dated 10/26/24, showed the patient’s last urinary catheter change was on 10/26/24. The SN note dated 12/31/24, showed last catheter change was performed on 12/31/24. Documentation showed the patient has “Foley catheter which is due for changing.” Documentation showed SN “cleaned the patient as needed Foley changed/reinforced infection control.” The SN note dated 1/1/25, showed last catheter change was performed on 1/1/25. * However, there was no documented evidence indication for the catheter change on 1/1/25. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1a. Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 3/20/24 to 5/28/24, cited SN visits 1W9. The POC showed SN to performed comprehensive observation and assessment of all body systems. The POC showed SN to teach disease processes and management, preventive measures, signs and symptoms of complications/exacerbations with emphasis on Type 2 DM. The POC also include SN to check VS and oxygen saturation every visit and notify MD if less than 90%. * Review of the SN visit notes dated 4/3, 4/8, 4/17, and 4/24/24 showed the SN had performed body system assessment. The body system assessment includes endocrine. The endocrine assessment showed a check marked on the section of no problem. However, the assessment was inconsistent with the POC. * Review of the SN notes dated 4/3 and 4/8/24 on the section of the respiratory assessment, showed the lung sounds were clear. In addition, on the section of Additional SN notes notes showed the patient was not in distress. However, the SN documented the patients oxygen saturation was 67% which was inaccurate. * Review of the SN visit notes dated 4/3, 4/8, 4/17 and 4/24/24 on the section of additional SN notes showed the patient was assessed to have wound on the left heel. Wound treatment was provided. Review of the integumentary system assessment included the wound type. The section for wound type showed a check marked on "see wound assessment and treatment". However, review of the clinical record failed to show documented evidenced of the wound assessment and treatment form as checked on the assessment. b. The POC, for the certification period from 1/30/24 to 3/29/24, cited SN visits 1W9. The POC showed SN to performed comprehensive observation and assessment of all body systems. * Review of SN notes dated 2/16/24 on the section of narrative notes, showed the SN had provided wound care to the patients stage 2 pressure injury to the left heel. Clean with normal "sailing", "Sarah form" and cover it with nonadherent dressing. Instructed the facility caregivers on putting "health" protector. * Review of the SN notes dated 2/9, 2/16, 2/21, 2/28, 3/9 and 3/21/24, showed the SN had performed integumentary assessment. The assessment included wound type. on the section for wound type showed a check mark on "see wound assessment and treatment form". However, review of the clinical record failed to show documented evidenced of the wound assessment and treatment form as checked on the assessment. * The POC showed SN to teach disease processes and management, preventive measures, signs and symptoms of complications/exacerbations to include type 2 diabetes mellitus. Review of the SN visit notes dated 2/9, 2/16, 2/28, 3/9, 3/11 and 3/21/24 showed the SN had performed body system assessment to include endocrine. However, the endocrine section for no problem had a check mark which was inaccurate. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. Review of the SOC OASIS dated 5/8/24, showed the patients primary language was Vietnamese. Review of the face sheet, showed the patients primary language was Vietnamese. The patients secondary language was English. However, the Recertification OASIS dated 11/2/24, showed the patient's primary language was English instead of Vietnamese. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked as to the patients primary language. The DPCS replied. The patients primary language was English and not Vietnamese. They overlook the Vietnamese documentation. The DPCS was informed and acknowledged the finding.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure care and services were provided in accordance with the care plan for one of seven sampled patients (Patient 3), creating the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for HHA services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC, for the certification period from 11/10/24 to 1/8/25, cited CHHA 1W4 and reassess. The POC showed the CHHA to continue providing basic personal care, such as bathing, dressing and grooming. Assisting the patient in ambulating and transferring. Review of the Home Health Aide Care Plan for the certification period from 11/10/24 to 1/8/25, showed the assignment for the CHHA every visit. The assignment included for personal care, bathing, assisting with ambulation, mobility and light housekeeping in the bathroom. The assignment also includes to check the vital signs - blood pressure, temperature, pulse, respiration and pain scale every visit. A joint home visit with CHHA was conducted on 1/8/25 at 1330 hours, to Patient 3's home. The CHHA provided the basic personal care as ordered in the POC. However, the CHHA failed to check the patient's vital signs as ordered on the care plan. On 1/8/25 at 1448 hours. the CHHA was asked if she needed to check the patient vital signs. The CHHA replied, forgot to check it this time. The CHHA was informed and acknowledged the findings. On 1/14/25 at 1239 hours, the DPCS was informed of the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency's Administrator failed to be responsible for the day-to-day operations related to the written agreements with Contractors 1, 2, 3, 4, 5, and 6. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. d. Review of the written agreements between the hospice and Contractor 6 was initiated on 1/14/25. The written agreements with Contractor 1 did not include the roles and responsibilities of the program and the contracted providers in the coordination and evaluation of care and services provided. On 1/14/25 at 1159 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. a. Review of the written agreement between the agency and contractor 1 was conducted on 1/14/25. The written agreement provided RN and PT services. However, the written agreement failed to include the role of the agency and the contractor in patient admission process, patient assessment and scheduling of visits or hours. In addition, the written agreement failed to include the procedures for determining charges for PT services. b. Review of the written agreement between the agency and the Contractor 2, showed the nature and scope of services to be provided was for RN. However, the contract was for LVN. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment, scheduling of visit hours and discharge planning. c. Review of the written agreement between the agency and the Contractor 3, 4 and 5 showed the written agreement provided RN services. However, the written agreement failed to include the roles of the agency and the contractor in patient admission process, patient assessment and scheduling of visits or hours. On 1/14/25 at 1059 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS reviewed the written agreement and acknowledged the findings.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency's Administrator failed to be responsible for the day-to-day operations as the agency's P&P related to wound assessments was completed in accordance with the agency's P&P for two of 7 sampled patients (Patients 1 and 7). In addition, two contracted employee's (LVN 2 and RN 2) did not complete the orientation program. The performance evaluation and skills competency were not completed by LVN 2. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. b. Review of Patient 7's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The start of care assessment dated 10/29/24, showed the patient had Stage 2 left heel pressure injury. Documentation showed the size was 4 cm (length) X 5 cm (width). However, there was no documented evidence weekly wound assessment was conducted on Week 2 (11/2/24 to 11/9/24), Week 3 (11/10/24 to 11/16/24), Week 4 (11/17/24 to 11/23/24), Week 5 (11/24/24 to 11/30/24), Week 6 (12/1/24 to 12/7/24), Week 7 (12/8/24 to 12/14/24), and Week 8 (12/15/24 to 12/21/24) as per the agency’s P&P. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1. The agency's P&P titled Administrator revised 3/2018, showed the Administrator is responsible for the agency's functions and all day - to -day operations of the agency. The Administrator of the agency has the responsibilities to include complying with applicable laws and regulations. Review of the agency's P&P titled Personnel Records revised 9/2019, showed personnel files will be established and maintained for all staff. The personnel record or personnel information for an employee will include but not limited to job description, reviewed and signed by employee. Review of the agency's P&P titled Employee Orientation revised 9/2019, showed the orientation checklist will be used to document orientation for all staff, including contract staff. Orientation for each employee will minimally included confidentiality and privacy of protected health information and emergency plan. Review of the agency's P&P titled Staff Competency Program revised 3/2018, showed the agency will provide for initial and ongoing competency assessments for all patient care staff by qualified individuals. The procedure includes the patient care staff will be competency assessed for each new employee (including contract employees) during orientation. The competency evaluation checklist will be completed and retained in the employee's record. Review of the personnel file was conducted on 1/13/25 for the following contracted staff: -LVN 2's personnel file showed the hiring date was 10/18/23. However, there was no documented evidence of the orientation, performance evaluation and skills competency were completed upon employment as per P&P. In addition, the file failed to include the employees signed job description as per P&P. Further review of the file failed to show documented evidenced of the training for confidentiality and privacy of protected health information and emergency plan was completed as part of the orientation as per P&P. -RN 2's personnel file showed the hiring date was 6/28/22. However, there was no documented evidence of the orientation completed upon employment. In addition, the file failed to include the employees signed job description as per P&P. Further review of the file failed to show documented evidenced of the training for confidentiality and privacy of protected health information was completed upon orientation as per P&P. On 1/13/25 at 1425 hours, an interview and concurrent document review was conducted with the HR Manager. The HR Manager was informed and acknowledged the findings. 2. The agency's P&P titled Assessment Of Wound/Pressure Ulcer undated showed home care should use a risk assessment tool to determine risk and plan accordingly. Wound assessment needs to be done by all clinicians during initial admission, on a weekly and as needed for new change of condition. The pressure ulcer assessment guide showed in assessing the wound/pressure ulcer, the following parameters should be address consistently: site, stage of ulcer, and size of ulcer (include length, width and depth) presence of tunneling or undermining, presence of necrotic tissue (slough or eschar), drainage amount, color, odor, pain and condition of surrounding tissue. a. Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. *Review of the Recertification OASIS dated 3/29/24 on the section of Wound/Lesion showed the patient was assessed to have an unstageable pressure injury to the left heel measuring 1.5 x1.5 cm; odor and drainage - none. However, the wound assessment was incomplete as per P&P. *Review of the SN visit notes dated 4/3, 4/8, 4/17 and 4/24/24 on the section of additional SN notes showed the patient was assessed to have wound on the left heel. Wound treatment was provided. However, review of the clinical record failed to show documented evidenced of a completed wound assessment as per P&P. *Review of the Discharge OASIS dated 4/4/24 on the section of Wound/Lesion showed the patient was assessed to have an unstageable pressure injury to the left heel measuring 1.5 x1.5 cm; odor - none; and drainage - small; color - serosanguinous; consistency - thick However, the wound assessment was incomplete as per P&P. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the clinical records were complete, authenticated and accurate for five of seven sampled patients (Patients 1, 3, 4, 5, and 8), creating the risk of substandard care provided to these patients as their clinical information was not complete. The agency's P&P titled Medical Record Entries and Authentication revised 3/2018 showed all medical record entries will be dated and authenticated. The procedure includes all entries in the medical records will be complete and appropriately authenticated, dated and timed. All entries in the medical records will be authenticated by staff signature and title. If automated clinical record system is used, authentication includes a signature and title or secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry, in accordance with the state law. 1. Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. a. Review of the Recertification OASIS dated 3/29/24, showed the RN had performed a comprehensive assessment. However, on the section for the RN's attestation for the printed name/ signature and date was left blank. b. Review of the Case Conference for the certification period 3/30/24 to 5/28/24, showed a case conference was conducted. The participant in the case conference showed an RN. However, the section for the signature of supervisor and date was left blank. c. Review of the SN notes dated 3/9 and 3/11/24, showed the SN had performed an assessment. However, the section for the clinician signature, title and date was left blank. In addition, review of the clinical record showed a communication note dated 3/11/24. however, the section on the communication note for the staff name, signature and date was left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 8's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all body systems. Review of the Communication Note dated 12/9/24, showed a communication related to medication. However, the section for the staff name/signature and date was left blank. b. The POC for the certification period from 10/11/24 to 12/9/24, cited for PT evaluation and treatment. Review of the Physicians Order dated 10/30/24, showed an order to discharge with PT and follow up with MD. The order showed the staff name/signature and date. However, the section for the physicians name /signature was left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 3a. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. Review of the Home Health Aide Care Plan for the certification period from 11/10/24 to 1/8/25, showed the CHHA visit frequency, assignment for the every visit, special instructions, problems and goals. However, the section for the names, signature and dates for CHHA and the RN/Therapist were blank. On 1/14/25 at 1239 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. Review of the SN notes dated 11/14, 11/21 and 11/30/24, showed the SN had performed an assessment. However, the section for the clinician signature, title and date was left blank. In addition, review of the SN note dated 1/4/25, on the section of narrative note showed declined visit, was sleeping. However, the section for the clinician signature, title and date was left blank. c. Review of the communication notes dated 9/13/24, showed a communication order related to change in PT visit frequency. However, the section for the clinician signature, title and date was left blank. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 4. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC for the certification period from 11/4/24 to 1/2/25 cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems. Review of the SN visit notes dated 11/8, 11/15, 11/22 and 11/25/24 showed the SN had performed an assessment. However, review of the SN visit notes on the section of the clinician signature, title and date was left blank. In addition, review of the Communication Note dated 1/2/25, the section of the clinician signature, title and date was left blank. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 5. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. The SN note dated 11/21 and 11/27/24, showed the SN conducted the visits. * However, there was no documented evidence of the clinician’s electronic signature. On 1/14/24 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. Findings: The agency's P&P titled Medical Record Entries and Authentication revised 3/2018 showed all the medical record entries will be dated and authenticated. The procedure includes all entries in the medical records will be complete and appropriately authenticated, dated and timed. All entries in the medical records will be authenticated by staff signature and title. If automated clinical record system is used, authentication includes a signature and title or secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry, in accordance with the state law. 1. Review of Patient 1's closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. a. Review of the Recertification OASIS dated 3/29/24, showed the RN had performed a comprehensive assessment. However, on the section for the RN's attestation for the printed name/ signature and date were left blank. b. Review of the Case Conference for the certification period 3/30/24 to 5/28/24, showed a case conference was conducted. The participant in the case conference showed an RN. However, the section for the signature of supervisor and date were left blank. c. Review of the SN notes dated 3/9 and 3/11/24, showed the SN had performed an assessment. However, the section for the clinician signature, title and date were left blank. In addition, review of the clinical record showed a communication note dated 3/11/24. However, the section on the communication note for the staff name, signature, and date were left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 8's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all the body systems. Review of the Communication Note dated 12/9/24, showed a communication related to medication. However, the section for the staff name/signature and date were left blank. b. The POC for the certification period from 10/11/24 to 12/9/24, cited for PT evaluation and treatment. Review of the Physician's Order dated 10/30/24, showed an order to discharge with PT and follow up with MD. The order showed the staff name/signature and date. However, the section for the physician's name /signature was left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 3a. Review of Patient 3's clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. Review of the Home Health Aide Care Plan for the certification period from 11/10/24 to 1/8/25, showed the CHHA visit frequency, assignment for every visit, special instructions, problems and goals. However, the section for the names, signature, and dates for CHHA and the RN/Therapist were blank. On 1/14/25 at 1239 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. Review of the SN notes dated 11/14, 11/21, and 11/30/24, showed the SN had performed an assessment. However, the section for the clinician signature, title, and date were left blank. In addition, review of the SN note dated 1/4/25, on the section of narrative note showed declined visit, was sleeping. However, the section for the clinician signature, title, and date were left blank. c. Review of the communication notes dated 9/13/24, showed a communication order related to change in PT visit frequency. However, the section for the clinician signature, title, and date were left blank. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 4. Review of Patient 5's clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC for the certification period from 11/4/24 to 1/2/25 cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all the body systems. Review of the SN visit notes dated 11/8, 11/15, 11/22 and 11/25/24 showed the SN had performed an assessment. However, review of the SN visit notes on the section of the clinician signature, title and date was left blank. In addition, review of the Communication Note dated 1/2/25, the section of the clinician signature, title and date was left blank. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 5. Review of Patient 4's clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. The SN note dated 11/21 and 11/27/24, showed the SN conducted the visits. * However, there was no documented evidence of the clinician’s electronic signature. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness, Change of Location, and Partial Extended Recertification surveys. Representing the California Department of Public Health: Surveyors 39796, HFEN; 39210, HFEN; and 39539, HFEN.The survey team entered the HHA on 3/15/22 at 0945 hours. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: LVN: Licensed Vocational NurseP&P: Policy and Procedure

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure their emergency preparedness plan and P&Ps included a process for cooperation and collaboration with the state and federal emergency preparedness officials. This created the potential risk of not maintaining an integrated response during a disaster or emergency situation. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s P&Ps and plan showed the agency included the process for cooperating and collaborating with the local and regional officials; however, the agency's P&Ps did not include the agency's process in cooperating and collaborating with the state and federal agency officials during a disaster or emergency situation. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan and P&Ps included procedures to inform the state officials regarding patients in need of evacuation from their residences due to an emergency situation based on the patient’s medical condition and home environment. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s P&Ps and plan showed the agency had procedures to inform the local emergency preparedness officials regarding patients in need of evacuation from their residences in the event of an emergency situation. However, the agency's P&Ps did not include when and how the information will be communicated to the state officials in the event a patient needed the evacuation at any time due to an emergency situation based on the patient's medical condition and home environment. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan and P&Ps included procedures to inform state officials of any on-duty staff they are unable to contact in the event of an emergency. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s P&Ps and plan showed the agency had the procedures to follow up with patients to determine the services needed in the event of an interruption in services due to an emergency or disaster. However, the agency’s P&Ps and plan did not include when the agency will inform the state officials of any on-duty staff that they are unable to contact. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan and P&Ps included the updated names and contact information of the entities providing services under agreement, patients' physician, and volunteers. This failure had the potential to negatively impact the patients' care needs during the emergency events. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s P&Ps and plan showed the agency had a communication plan with the names and contact information of the agency’s staff. However, the communication plan failed to show the updated names and contact information of the entities providing services under agreement, patients' physician, and volunteers. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan and P&Ps included the contact name and information for the federal emergency preparedness staff. This failure had the potential to negatively impact the patients' care needs during the emergency events. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s P&Ps and plan showed the agency had a communication plan including the contact information for the state, regional, and local emergency preparedness staff. However, the communication plan failed to include the contact information for the federal staff. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan and P&Ps included the information related to the alternate means of communicating with the federal, state, regional, and local emergency management agencies. This created the risk of not being able to communicate to meet the patient and staff needs during an emergency. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s P&Ps and plan showed the primary and alternate means for communicating with the agency’s own staff. However, the plan did not include the alternate means of communicating with the federal, state, regional, and local emergency management agencies. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan and P&Ps included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This failure created the risk of not providing the necessary care and services to the patients during the emergency events. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s communication plan did not include a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the agency conducted additional exercises that may include every two years, opposite the year the full-scale or functional exercise was conducted. This failure created the risk of the agency's staff not knowing what to do in case of emergency. Review of the agency’s P&Ps titled Emergency Preparedness Program 2021 and Emergency Operations Plan and Policy dated December 2019 showed the agency’s P&Ps did not address the requirement for the agency to conduct additional exercises that may include, but is not limited to a second full-scale exercise, mock disaster drill, or a tabletop exercise that is led by a facilitator and includes a group discussion using a narrated clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. In addition, the agency was unable to provide documented evidence to show additional exercises were conducted. On 3/22/22 at 0934 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

The following reflects the findings of the California Department of Public Health during the concurrent Partial Extended Recertification, Change of Location, and Emergency Preparedness surveys. Representing the California Department of Public Health: Surveyors 39796, HFEN; 39210, HFEN; and 39539, HFEN On 3/15/22 at 0945 hours, the concurrent change of location and recertification surveys was conducted at the agency's new location at 12362 Beach Boulevard Suite 29C, Stanton, CA 90680. An entrance conference was conducted with LVN 1/Case Manager. LVN 1/Case Manager stated the agency was fully operational at the new location. The survey team conducted 3 home visits and reviewed 5 active and 2 closed clinical records. Glossary: ADL: Activities of Daily Living BID: Twice a Day BPH: Benign Prostatic Hyperplasia (a condition in men in which the prostate is enlarged and not cancerous) CHF: congestive heart failure, condition in which the heart can’t pump enough blood to meet the body's needs CHHA: Certified Home Health Aide CLIA: Clinical Laboratory Improvement Amendments CMS: Centers for Medicare and Medicaid Services COVID-19: an infectious disease caused by the SARS-CoV-2 virus Diabetes: a disease in which there are high blood sugar levels over a prolonged period dl: deciliter DPCS: Director of Patient Care Services DVT: Deep Vein Thrombosis (blood clots in a deep vein) F: Fahrenheit g: gram(s) H: Hour Hepatitis: inflammation of the liver H1N1: respiratory infection cause by an influenza strain HS: Hour of sleep HHA: Home Health Agency HR: Human Resources Hypoglycemia: low blood sugar Hyperglycemia: high blood sugar LVN: Licensed Vocational Nurse mcg: microgram(s) meq: milliequivalent mg: milligram(s) ml: milliliter(s) mmHg: millimeter(s) of mercury MSW: Medical Social Worker NS: Normal Saline OASIS: Outcome and Assessment Information Set OT: Occupational Therapy/Therapist P&P: Policy and Procedure PCG: Primary Caregiver Peritoneal Dialysis (PD): a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your bodyPO: By mouth POC: Plan of Care PRN: As Needed PT: Physical Therapy/Therapist PTA: Physician Therapy Assistant Q: Every QD: Daily RN: Registered Nurse SN: Skilled Nursing/Nurse SOC: Start of Care Stage 3 pressure injury: Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and or eschar maybe visible. Tetanus: a bacterial infection that causes painful muscle spasms Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. W: week WNL: within normal limit

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the agency failed to ensure the written information was provided to the patient's preferred language for one of the seven sampled patients (Patient 4), creating the risk of violating the patient's rights and not providing quality of care and services to this patient. Findings: The agency's P&P titled Patient Bill of Rights and Responsibilities revised 2009 showed if a patient or his/her representative's understanding English is inadequate for the patient's comprehension of his/her rights and responsibilities, the information must be provided in a language or format familiar to the patient or his/her representative. The patient have the right to be informed of of the patient's rights in a language and manner the individual understands. Patient 4's clinical record review was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22 and 3/6/22 to 5/4/22. The POC, for the certification period from 3/6/22 to 5/4/22, cited SN visits 1W9 (one visit a week for nine weeks) and as needed if there is any change in condition. The POC also cited CHHA visits 1W4. Review of Patient 4's Profile showed the patients primary language was Spanish. A joint home visit with CHHA was conducted on 3/17/21 at 1100 hours, to Patient 4's home. The patient was provided with the agency's admission packet. The admission packet included the Notice of Medicare Non Coverage written in patient's primary language. However, the Admission Service Agreement, Patient's Rights and Responsibilities, and other documents were provided in English. On 3/17/22 at 1200 hours, the patient was asked if he was able to read and understand the written documents on his admission packet. The patient replied he did not understand any of it. The CHHA stated the patient spoke Spanish only. The CHHA verified the admission documents were in English. On 3/22/22 at 0934 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. She was asked if the agency needed to provide the consent and other written documents in Spanish. She replied yes, they should have provided the consents and other documents in Spanish. The DPCS/Administrator was informed and acknowledged the findings.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for six of seven sampled patients (Patients 1, 2, 3, 4, 6, and 7), creating the risk of not identifying and addressing the care needs timely for these patients. Findings: The agency's P&P titled Initial Assessment/Comprehensive Assessment revised January 2020 showed the RN, PT, or SLP must conduct the initial assessment visits within 48 hours of the referral, within 48 hours of the patient's return home or on the physician ordered start of care date. The completion of the comprehensive assessment must be in a timely manner consistent with the patient needs, but no later than 5 calendar days after the start of care. 1. Review of Patient 1's closed clinical record was initiated on 3/15/22. The clinical record showed the SOC was 6/26/21. The patient was certified for home health services during the certification period from 6/26/21 to 8/24/21. The patient was discharged on 8/24/21. The initial comprehensive assessment dated 6/26/21, showed the RN had assessed the patient's immunization status. However, the immunization assessment was incomplete. On 3/22/22 at 1102 hours, an interview with concurrent closed clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22 and 3/6/22 to 5/4/22. a. Review of the Recertification Order dated 3/2/22, showed a verbal order for the recertification period from 3/6/22 to 5/4/22. Review of the recertification OASIS dated 3/2/22, showed the RN had performed body system assessment. The patient's primary diagnosis was hypertensive heart disease without heart failure. Review of the patient's Medication Profile, for the certification period from 3/5/22 to 5/4/22, showed a medication for atrial fibrillation. However, the RN failed to assess and complete the patient's other diagnoses, height and weight, nutritional requirements, heart sound, pulses, capillary refill, home oxygen risk assessment, and compliance checklist as part of the comprehensive assessment. On 3/22/222 at 0841 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked as to the timeline of the completion of the recertification OASIS. The DPCS/Administrator stated the patient was just recertified and not fully coded. The DPCS/Administrator further stated it should have been completed within 5 days of the recertification order. The DPCS/Administrator then provided a new copy of the recertification OASIS. The DPCS/Administrator was further asked as to when was the recertification OASIS completed. The DPCS/Administrator replied it was completed on 3/18/22, more than five days of the recertification order. The DPCS/Administrator was informed and acknowledged the findings. b. The POC, for the certification period from 1/5/22 to 3/5/22, cited SN visits 2W4, 1W5 and PRN visits for comprehensive observation and assessment of all body system. Review of the initial comprehensive assessment dated 1/5/22, showed the RN had performed the comprehensive assessment. However, the initial comprehensive assessment failed to show documented evidenced the RN had assessed the patient's health screening and immunization status for hepatitis, tetanus, and H1N1. On 3/22/22 at 0945 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the findings. 3. Review of Patient 2's closed clinical record showed the SOC was 10/12/21. The closed clinical record showed the patient received home health services during the certification period from 10/12/21 to 12/10/21. Review of the Comprehensive SOC assessment dated 10/12/21, showed no documented evidence the health screening was assessed. The form also showed incomplete assessment of Patient 2’s most recent immunizations, including hepatitis, tetanus, and H1N1. On 3/22/22 at 0901 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings. 4. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification periods from 12/24/21 to 2/21/22 and 2/22/22 to 4/22/22. a. Review of the Comprehensive SOC assessment dated 12/24/21, showed no documented evidence the health screening was assessed. The form also showed incomplete assessment of Patient 3’s most recent immunizations, including hepatitis and tetanus. b. Review of the Comprehensive Recertification assessment dated 2/18/22, showed no documented evidence the patient’s living arrangement, height and weight, and home oxygen risk assessment were assessed. On 3/22/22 at 0910 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings. 5. Review of Patient 7's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/6/21. The patient was certified for home health services during the certification period from 12/6/21 to 2/3/22. a. The initial comprehensive assessment dated 12/6/21, showed the RN had performed the initial comprehensive assessment. However, there was no documented evidence the patient's immunizations related to the Covid-19 vaccine were assessed. On 3/22/22 at 0940 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/ Case Manager was informed and acknowledged the findings. b. The recertification assessment dated 2/3/22, showed the RN had performed the recertification comprehensive assessment. However, there was no documented evidence a diabetic foot examination was performed. Review of Patient 7's POC during the certification period of 2/4/22 to 4/4/22 showed Patient 7's primary diagnosis was type 2 diabetes mellitus. On 3/22/22 at 0841 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 was informed and acknowledged the finding. 6. Review of Patient 6's clinical record was initiated on 3/16/22. The clinical record showed the SOC was 11/24/21. The patient was certified for home health services during the certification period from 11/24/21 to 1/22/22. The patient's plan of care showed Patient 6 was admitted to home health with diagnoses of hypertensive heart disease with heart failure and diabetes mellitus type 2. The initial comprehensive assessment dated 11/24/21, and the recertification assessment dated 1/20/22, showed the RN had performed the initial comprehensive assessment. The assessment showed the patient had no issue with performing her in-home peritoneal dialysis (PD). However, review of the patient's genitourinary and integumentary assessments showed the status was within normal limits and no additional assessments were completed of the patient's PD catheter. Further review of the initial comprehensive assessment failed to show documented evidence a diabetic foot examination and care was completed. On 3/22/22 at 0940 hours, an interview and concurrent clinical record review was conducted with LVN 1/ Case Manager. LVN 1/ Case Manager was informed and acknowledged the findings.

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 clinical record review, the agency failed to ensure the medication profiles were updated for four of seven sampled patients (Patients 3, 4, 5, and 6), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. M. A.Bon The agency P&P titled Medication Reconciliation revised March 2018 showed the agency will reconcile patient's medications at the time of admission and an ongoing basis in order to identify any potential adverse effects and drug interactions, including ineffective therapy, significant side effects, significant drug interactions, duplicate drug therapy and non compliance with drug therapy. The procedure includes medications ordered while the patient is receiving care will be compared to the medication list/profile, The medication list/profile will be updated with each new or changed medication. The patient's medication list in home will be updated. 1. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22 and 3/6/22 to 5/4/22. The Medication profile for the certification period from 3/6/22 to 5/4/22, showed the patient's medications included the following: - amiodarone hydroxychloride (anti-arrythmia) 200 mg one tablet PO QD for atrial fibrillation; - potassium chloride (mineral supplement) 20 meq ER one tablet PO QD; - vitamin D3 gluten free (supplement) 125 mcg one tablet PO QD for 30 days; - multivitamins with minerals (supplement) one tablet PO QD; - hydrocodone-acetaminophen (opioids) 10 mg-325 mg one tablet PO Q4H PRN for moderate pain; - zolpidem tartrate (sedative) 5 mg one tablet PO QD PRN; - acetaminophen (analgesic) 325 mg two tablets PO Q4H PRN for mild pain, do not exceed 3 grams/day from all other sources; - pantoprazole sodium (anti-ulcer) 40 mg tab DR one tablet PO QD; - DOK (laxative) 100 mg one tablet PO QD, hold for looses stool; - albuterol sulfate unit dose (bronchodilator) 2.5/3ml vial-nebule inhale one vial via nebulizer PO Q6H for shortness of breath; - vitamin C (supplement) 500 mg one tablet PO QD for 30 days; - atorvastatin calcium (antilipidemic) 20 mg one tablet PO QHS; - tamsulosin hydrochloride (anti adrenergic) 0.4 mg one capsule PO QD for BPH; - Eliquis (anticoagulant) 2.5 mg one tablet PO QD for DVT prophylaxis; - furosemide (diuretics) 20 mg one tablet PO BID for CHF; - Senecon-S (laxative) 8.6mg/50 mg one tablet PO Q HS hold for loose stool and - metoprolol tartrate (beta blockers) 100 mg one tablet PO BID for hypertension, hold for SBP below 100 mmhg. A joint home visit with CHHA was conducted on 3/17/21 at 1100 hours, to Patient 4's home. Review of the patient medications with CHHA showed the following: - Eliquis (anticoagulant) 2.5 mg one tablet PO BID - atorvastatin calcium (antilipidemic) 20 mg one tablet PO Q HS - metoprolol succinate (beta blockers) 100 mg one tablet PO BID. - potassium chloride (mineral supplement) 20 meq ER one tablet PO QD - furosemide (diuretics) 20 mg one tablet PO BID - tamsulosin hydrochloride ( anti adrenergic) 0.4 mg one capsule PO QD - Geri-kot 6.8 mg one tablet PO as needed and - Tylenol extra strength (acetaminophen) 500 mg one tablet PRN However, amiodarone, vitamin D3, multivitamins, hydrocodone-acetaminophen, zolpidem, pantoprazole sodium, DOK, albuterol sulfate, vitamin C, Senecon-S medications were not available at Patient 4's home. In addition, Patient 4 was taking Geri-kot but not listed in the medication profile; Eliquis 2.5 mg two times a day instead of daily as listed in the medication profile: and Tylenol ES 500 mg one tablet instead of 325 mg two tablets as listed in the medication profile On 3/17/22 at 1230 hours, an interview with concurrent clinical record review was conducted with the patient and the CHHA. They were asked if these were all the medications Patient 4 was currently taking. The patient replied yes. The CHHA verified the medication list provided by the agency was not updated. On 3/22/22 at 0934 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, cited SN visits 1W9 and as needed if there is any change in condition or plan of care. The Recert Reconciled Medication Profile dated 2/18/22, showed the patient’s medications included the following: - ascorbic acid (supplement) 500 mg one tablet by mouth daily; - Celebrex (arthritis) 200 mg one tablet by mouth daily; - cholecalciferol (supplement) 25 mcg one tablet by mouth daily; - clonidine (hypertension) 0.1 mg one tablet by mouth twice a day; - Crestor (anticholesterol) 10 mg one tablet by mouth daily; - docusate sodium (laxative) 250 mg one tablet by mouth twice a day; - melatonin (sleeping aid) 5 mg one tablet by mouth daily; - methocarbamol (muscle spasm) 500 mg one tablet by mouth every eight hours as needed for muscle spasm; - milk of magnesia (laxative) 1200 mg per 15 ml oral suspension, to give 30 ml by mouth daily as needed for constipation; - Miralax (laxative) 17 g per scoop, to give one scoop by mouth in the morning; - multivitamin-minerals (supplement) one tablet by mouth daily; - oxycodone (opioid) 10 mg one tablet by mouth every six hours as needed for severe pain; - oxycodone (opioid) 5 mg one tablet by mouth every six hours as needed for moderate pain; - Senokot (laxative) 8.6 mg one tablet by mouth at bedtime; - Tylenol (analgesic) 325 mg two tablets by mouth every four hours as needed for mild pain; and - olmesartan medoxomil (hypertension) 5 mg one tablet daily. On 3/16/22 at 0940 hours, a joint home visit with LVN 2 was conducted to Patient 3's home. Review of the patient’s medications with LVN 2 and Patient 3 showed the following: - vitamin D3 1000 mg one tablet by mouth daily; - Super C with vitamin D3 and zinc one tablet by mouth daily; - celecoxib (Celebrex) 100 mg one tablet by mouth twice a day; - olmesartan medoxomil 5 mg one tablet by mouth at bedtime; - rosuvastatin 20 mg one tablet by mouth daily; - multivitamin one tablet by mouth daily; and - melatonin 5 mg by mouth at bedtime as needed for sleep. However, cholecalciferol, clonidine, Crestor, docusate sodium, methocarbamol, milk of magnesia, Miralax, oxycodone, Senokot, and Tylenol medications were not available at Patient 3's home. In addition, Patient 3 was taking vitamin D3, Super C with vitamin D3, and rosuvastation medication but were not listed in the medication profile; and Patient 3 was taking Celebrex 100 mg instead of 200 mg as listed in the medication profile. On 3/16/22 at 1015 hours, an interview was conducted with Patient 3. Patient 3 verified the medications reviewed were the only medications she was currently taking. On 3/16/22 at 1020 hours, an interview and concurrent clinical record review was conducted with LVN 2. LVN 2 verified Patient 3’s medication profile was not updated. 3. Review of Patient 5's clinical record was initiated on 3/17/22. The clinical record showed the SOC was 2/26/22. The patient was certified for home health services during the certification periods from 2/26/22 to 4/26/22. Review of the Medication Profile, for the certification period 2/26/22 to 4/26/22, showed the patient's medications included Keppra (antiseizure) 500 mg one tablet by mouth three time daily, Vimpat (antiseizure) 150 mg one tablet by mouth two times daily and Probiotic (supplement) Advance strength one capsule by mouth once daily. On 3/18/22 at 1100 hours, a joint home visit was conducted with the PTA to Patient's 5 home. Review of the patient's medications profile with the PTA and the PCG showed the patient was on Keppra 500 mg one tablet by mouth three times daily, Vimpat 150 mg one tablet by mouth twice daily, Probiotic Advance strength one capsule by mouth once daily, calcium citrate magnesium and zinc with vitamin D3 by mouth one to two tablets daily, vitamin D 350 meq one soft gel by mouth, daily, and CBD one capsule three times a day by mouth. However, calcium citrate, vitamin D, and CBD medications were not listed on the medication profile; and Patient 5 was taking Keppra 500 mg two tablets by mouth in the morning and three tablets at night instead one tablet three times a day as per the medication profile. On 3/22/22 at 0940 hours, an interview with concurrent clinical record review was conducted with LVN 1/ Case Manager. LVN 1/ Case Manager was informed and acknowledged the findings. 4. Review of Patient 6's clinical record was initiated on 3/16/22. The clinical record showed the SOC was 11/24/21. The patient was certified for home health services during the certification periods from 11/24/21 to 1/22/22 and 1/23/22 to 3/23/22. Review of the POC, for the certification period 1/23/22 to 3/23/22, showed the patient's medications included the following: - acetaminophen (analgesic) 500 mg take one tablet every six hours, as needed for severe pain (Pain level 7-10); - acetaminophen (analgesic) 300 mg/Codeine 30 mg tablet Take one tablet as needed every six hours for moderate pain (pain level 4-6); - aspirin (antiplatelet) 81 mg one tablet by mouth once daily for prophylaxis - atorvastatin 40 mg one tablet by mouth once daily for hyperlipidemia; - calcitriol (supplement) 0.5 mg one capsule by mouth once daily for supplement; - cetirizine hydrochloride (antihistamine) 10 mg one tablet by mouth once daily for allergies; - diclofenac (NSAID) 50 mg 1% gel apply two grams to affected area four times daily for pain; - docusate (stool softener) 100 mg capsule one capsule by mouth once daily for constipation; - hydralazine (antihypertensive) 25 mg one tablet by mouth once daily for hypertension; - Lasix (diuretic) 80 mg one tablet by mouth twice daily for fluid retention; - latanoprost (antiglaucoma) instill one drop into each eye nightly for glaucoma; - calcium carbonate 500 mg two tablets by mouth three times a day with meals for supplement; - mupirocin (antibiotic) 2% topical ointment, apply to wound once daily for wound care. Review of the Medication Profile, for the certification period 11/24/21 to 1/22/22 , showed the patient's medications included the following: - acetaminophen 500 mg take one tablet every six hours, as needed for severe pain (Pain level 7-10); - acetaminophen 300 mg/Codeine 30mg tablet Take one tablet as needed every six hours for moderate pain (pain level 4-6); - aspirin 81 mg one tablet by mouth once daily; - atorvastatin 40 mg one tablet by mouth once daily; - calcitriol 0.5 mg one capsule by mouth once daily; - cetirizine hydrochloride 10 mg one tablet by mouth once daily; - diclofenac 50 mg 1% gel apply two grams to affected area four times daily; - docusate 100 mg capsule one capsule by mouth once daily; - hydralazine 25 mg one tablet by mouth once daily; - Lasix 80 mg one tablet by mouth twice daily; - latanoprost instill one drop into each eye nightly; - calcium Carbonate 500 mg two tablets by mouth three times a day with meals; - mupirocin 2% topical ointment, apply to wound once daily; - calcium alginate dressing apply to wound on bilateral foot daily. On 3/22/22 at 0956 hours, an interview with concurrent clinical record review was conducted with LVN 1/ Case Manager. LVN1/Case Manager was asked why acetaminophen 500 mg was for severe pain while acetaminophen 300 mg with codeine was for moderate pain. LVN 1/Case Manager verified the order was not clarified with the physician. LVN 1/Case Manager stated the RN should have clarified the order and acknowledged the finding.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the completed discharge summary was sent to the primary care practitioner after discharge from the HHA for one of the seven sampled patients (Patient 1), creating the risk of not providing the necessary care and services to this patient after discharge from the HHA. Findings: Review of Patient 1's closed clinical record was initiated on 3/15/22. The clinical record showed the SOC was 6/26/21. The patient was certified for home health services during the certification period from 6/26 to 8/24/21. The Comprehensive Discharge dated 8/24/21, showed the patient was discharged from the HHA. However, there was no documented evidence a discharge summary was completed. On 3/22/22 at 1115 hours, an interview with closed clinical record review was conducted with the DPCS/ Administrator. The DPCS/Administrator was asked if the discharge summary was completed and sent to the physician. The DPCS/Administrator stated she would double check. On 3/22/22 at 1530 hours, the DPCS/Administrator provided the copy of the discharge summary and the transmittal sheet for the physician. Review of the Discharge Summary dated 8/24/21, showed documentation of the date of discharge, reason for discharge, overall status of patient at discharge and discharge instructions. However, the discharge summary did not include the patients diagnosis, problems identified, status of problem identified, services provided and summary of care provided by the HHA. In addition, the lists of medications was not included in the discharge summary that was sent to the physician. On 3/22/22 at 1530 hours, the DPCS/Administrator was informed and verified the findings.

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 clinical record review, the agency failed to ensure the physician was informed when the care and services were not provided timely as ordered for three of seven sampled patients (Patients 2, 6, and 7), creating the risk of not providing appropriate, consistent, and quality of care to these patients. Findings: 1. Review of Patient 6's clinical record was initiated on 3/16/22. The clinical record showed the SOC was 11/24/22. The patient was certified for home health services during the certification periods from 11/24/21 to 1/22/22 and 1/23/22 to 3/23/22. Review of the POC, for the certification period from 1/23/22 to 3/23/22, cited SN visits 2W5, 1W4, and as needed if there is any change in condition or plan of care. Review of the SN notes showed the last SN visit was 2/18/22. There was no documented evidence of any SN visit after 2/18/22, and there was no documented evidence the physician was notified of missed visits. On 3/22/22 at 0956 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager stated the SN did conduct a visit; however, the agency was unable to provide documented evidence of the SN visits. 2. Review of Patient 7's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/06/21. The patient was certified for home health services during the certification period from 12/06/21 to 4/4/22. Review of the POC, for certification period 2/4/22 to 4/4/22, showed SN visits 1w9 and as needed if there is any change in condition or plan of care. Review of the physician orders dated 2/10/22 showed an order for PT visits 1W1 and 2W3. Review of the PT notes showed the PT visits were conducted on 2/10, 2/17, 2/22, 2/24, 3/3, and 3/5/22. Review of the SN notes showed the SN visits on 2/9, 2/16, 2/23, and 3/8/22. However, there was no documented evidence of the SN visits after 3/8/22, and there was no documented evidence the physician was notified of the missed visits. On 3/22/22 at 0841 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified there were no physicians orders or communication notes to show the reason for missed visits between 2/23 and 3/8/22. LVN 3 was informed and acknowledged the findings. 3. Review of Patient 2's closed clinical record showed the SOC was 10/12/21. The clinical record showed the patient received home health services during the certification period from 12/11/21 to 2/8/22. The POC, for the certification period from 12/11/21 to 2/8/22, showed to notify the physician if there were any signs/symptoms of sudden decline in functional status; blood pressure changes out of range for systolic blood pressure greater than 160 mmHg or less than 90 mmHg; diastolic blood pressure greater than 90 mmHg or less than 60 mmHg; symptomatic hypertension crises; pulse greater than 100 beats per minute or less than 60 beats per minute; respirations greater than 28 breaths per minute or less than 12 breaths per minute; temperature greater than 100 F or less than 96 F; pain scale greater than 7 out of 10 interfering with activities or movement not relieved by pain medication/rest; and oxygen saturation level below 90%. Review of the SN notes dated 12/15/21, showed Patient 2 had a pulse rate of 59 beats per minute. However, there was no documented evidence the LVN had notified the physician of the patient’s pulse rate as per the POC. On 3/22/22 at 0850 hours, an interview and concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the finding.

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 interview and clinical record review, the agency failed to ensure an individualized plan of care was completed for one of the seven sampled patients (Patient 4), creating the risk of not addressing the care needs for this patient. Findings: The agency's P&P titled Plan of Care - CMS #485 and Physicians Order revised march 2019 showed 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 disciplines and the measurable outcomes that the agency 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 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 (every 60 days or more frequently when indicated by changes in the patients condition). Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22, and 3/6/22 to 5/4/22. a. The recertification assessment dated 3/2/22, showed the RN had performed a body system assessment including the integumentary system. The narrative notes showed Patient 4 had a wound on the abdomen and suprapubic area, which was described as healing well with no signs and infection; and a wound treatment was performed. However, review of the POC, for the certification period from 3/6/22 to 5/4/22, failed to include the wound assessment and treatment as identified on the recertification assessment. On 3/22/22 at 0841 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if the wound assessment and treatment needed to be in included in the POC. The DPCS/Administrator replied yes, it was missed and should have been included in the POC. b. The POC, for the certification period from 3/5/22 to 5/4/22, cited SN visit 1W9 and PRN if there is any changes in condition. However, review of the POC for the certification period from 3/5/22 to 5/4/22, failed to include the pertinent diagnoses, nutritional requirements, goals/rehabilitation potential/discharge plans and orders for disciplines and treatments. On 3/22/22 at 0841 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the findings. c. The POC for the certification period from 1/5/22 to 3/5/22, cited SN visits 2W4, 1W5, and PRN visits for comprehensive observation and assessment of all the body system. The POC also included SN to to teach the disease process and management, preventive measures, signs and symptoms of complications/exacerbations with emphasis on artificial openings of the urinary tract. Review of the initial comprehensive assessment dated 1/5/22, showed the RN documented a list of the patients disease process including diabetes as pertinent diagnoses There was no diabetes teaching and management included in the POC. On 3/22/22 at 0945 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if the diabetes teaching needed to be included in the POC. She replied yes, it should have been included in the POC and acknowledged the findings.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the physicians verbal orders were signed and dated by the qualified staff for furnishing or supervising the care for two of the seven of seven sampled patients (Patients 1 and 4), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: The agency's P&P titled Physician Orders - Verbal Orders revised March 2018 showed all verbal orders includes the patient's name, physician's name, date and time the order is taken and the signature of the person taking the order. The original order is documented and authenticated by licensed staff and submitted to the agency within three business days after the receipt. 1. Review of Patient 1's closed clinical record was initiated on 3/15/22. The clinical record showed the SOC was 6/26/21. The patient was certified for home health services during the certification period from 6/26/21 to 8/24/21. The patient was discharged on 8/24/21. Review of the Resumption of Care order dated 8/4/21 at 1300 hours, showed to resume care for Patient 1. However, the order did not include the name, discipline of the staff who received the verbal order, date, time, and physician's signature who provided the verbal orders. On 3/22/21 at 1102 hours, an interview with concurrent closed clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked as to the timeline for the physician's signature. The DPCS/Administrator stated, the physician should sign the orders within 30 days. The DPCS/Administrator was informed and acknowledged the findings. 2. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22, and 3/6/22 to 5/4/22. The POC, for the certification period from 3/5/22 to 5/4/22, cited SN visit 1W9 and PRN visits if there was any changes in condition. However, the POC did not include the name and signature of the responsible person who received the verbal orders from the physician. On 3/22/22 at 0841 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/ Administrator was informed of the finding. The DPCS/Administrator provided a new copy of the POC; however, the copy of the POC still did not include the name and signature of the responsible person who received the verbal orders from the physician. The DPCS/Administrator acknowledged the finding.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure any revisions to the plan of care of one of seven sampled patients (Patient 7) was communicated to the patient/patient representative or caregiver and physician, creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of Patient 7's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/6/21. The patient was certified for home health services during the certification periods from 12/6/22 to 2/3/22, and 2/4/22 to 4/4/22. Review of Patient 7's referral from the physician showed a note dated 11/19/21, to admit to home health for diagnoses of leg edema, congestive heart failure, and diabetes. Review of the agency's internal communication note dated 12/5/21, showed the family had requested for a delay in the start of services due to holidays. However, Patient 7's clinical record failed to show documentation of any changes in the plan of care related to the start of care with the home health agency. On 3/22/22 at 0940 hours, an interview was conducted with LVN 1/Case Manager. LVN 1/Case Manager stated she was responsible for documenting the communication note in the patient's record; however, she forgot to include it in the patient's clinical record. LVN 1/Case Manager was informed and acknowledged the findings.

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 clinical record review, the agency failed to coordinate the care needs of one of seven sampled patients (Patient 4), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 4's clinical record was initiated on 3/15/22, and showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22, and 3/6/22 to 5/4/22. Review of the recertification OASIS dated 3/2/22, showed the RN had performed a body system assessment. The narrative notes showed Patient 4 had a wound on the abdomen and suprapubic area which was described as healing well with no signs and infection; and wound treatment was performed. * Further review of the comprehensive assessment showed the RN assessed the patient's gastrointestinal system. However, the nutritional requirement was left blank. Review of the POC, for the certification period from 3/6/22 to 5/4/22, showed Patient 4's nutritional requirement was blank. On 3/22/22 at 0847 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if the physician was notified of the patient's wound. The DPCS/Administrator replied no. The DPCS/Administrator was also asked if the agency coordinated the patient's diet order. The DPCS/Administrator replied no and acknowledged the findings.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on interview and clinical record review, the agency failed to provide the written information related to services provided by the CHHA for one of seven sampled patients (Patient 4), creating the risk of not providing the necessary information to this patient. Findings: Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22, and 3/6/22 to 5/4/22. The POC, for the certification period from 3/6/22 to 5/4/22, cited CHHA visits 1W4. A joint home visit with CHHA was conducted on 3/17/21 at 1100 hours, to Patient 4's home. Patient 4 was asked for the written information related to CHHA services. The patient provided the admission packet. The CHHA assignment form did not include the frequency and services the CHHA would provide to Patient 4 during the certification period. On 3/17/22 at 1200 hours, the CHHA was asked if the CHHA assignment needed to be filled out. The CHHA verified the assignment form was blank and it should have been filled out. On 3/22/22 at 0934 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the finding.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview, and clinical record review, the agency failed to provide the written instructions on the SN visit schedule for three of seven sampled patients (Patients 3, 4, and 5), creating the risk of not providing the necessary information to these patients. 1. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, cited SN visits 1W9 and as needed if there is any change in condition or plan of care. On 3/16/22 at 0940 hours, a joint home visit with LVN 2 was conducted to Patient 3's home. LVN 2 was asked to show the visit schedule for Patient 3. LVN 2 stated the visit schedule was not updated and only showed the dates for 12/24/21, 1/8/22, 1/12/22, and 1/19/22. Further review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule for the months of February and March 2022. On 3/16/22 at 1013 hours, an interview and concurrent clinical record review was conducted with LVN 2. LVN 2 was informed and acknowledged the finding. LVN 2 stated the staff did not usually provide a visit schedule because they always call the day prior to visiting the patient’s home. X. R 1. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, cited SN visits 1W9 and as needed if there is any change in condition or plan of care. On 3/16/22 at 0940 hours, a joint home visit with LVN 2 was conducted to Patient 3's home. LVN 2 was asked to show the visit schedule for Patient 3. LVN 2 stated the visit schedule was not updated and only showed the dates for 12/24/21, 1/8/22, 1/12/22, and 1/19/22. Further review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule for the months of February and March 2022. On 3/16/22 at 1013 hours, an interview and concurrent clinical record review was conducted with LVN 2. LVN 2 was informed and acknowledged the finding. LVN 2 stated the staff did not usually provide a visit schedule because they always call the day prior to visiting the patient’s home. NES 2. Review of Patient 5's clinical record was initiated on 3/17/22. The clinical record showed the SOC was 2/26/22. The patient was certified for home health services during the certification period from 2/26/22 to 4/26/22. The POC, for the certification period from 2/26/22 to 4/26/22 , cited SN visits and frequency as 1w1, 2w1, and 1w7. On 3/18/22 at 1100 hours, a joint home visit with the PTA was conducted to Patient 5's home. The PTA was asked for the written instructions on the SN visit schedule. The PTA stated visit calendar was not updated and only showed date 3/16/22. Further review of the patient's admission packet showed no documented evidence of written instructions outlining the SN or PT visit schedule for March 2022. On 3/22/22 at 1130 hours, an interview and concurrent clinical record review was conducted with the LVN 1/ Case Manager. LVN 1/ Case Manager was informed and acknowledged the finding. M. A. Bon 3. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22 and 3/6/22 to 5/4/22. The POC, for the certification period from, cited SN visits 1W9 and as needed if there is any change in condition. The POC also cited CHHA visits 1W4. A joint home visit with CHHA was conducted on 3/17/21 at 1100 hours, to Patient 4's home. The patient was asked for the written instructions outlining the SN and CHHA visit schedule The patient provided the admission packet. The admission packet showed the written information provided by the agency including the visit calendar. However, the agency failed to provide an updated visit calendar outlining the SN and CHHA visit for the certification period 3/6/22 to 5/4/22. On 3/17/22 at 1200 hours, the CHHA was asked as to the previous date when she visited the patient. The CHHA stated, she visited the patient last Wednesday. She further stated, she visit the patient once a week. The CHHA was further asked if the visit calendar needed to be updated. The CHHA stated, yes, it should have been updated. The CHHA was informed and verified the finding. On 3/22/22 at 0934 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the findings. .

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to provide the name and information of the clinical manager for two of seven sampled patients (Patients 3 and 4), creating the risk of not providing the necessary information to these patients. 1. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, cited SN visits 1W9 and as needed if there is any change in condition or plan of care. On 3/16/22 at 0940 hours, a joint home visit with LVN 2 was conducted to Patient 3's home. Review of the patient's admission packet provided by the HHA showed no documented evidence of the written instructions outlining the name and contact information of the HHA's clinical manager. On 3/16/22 at 1025 hours, an interview and concurrent clinical record review was conducted with LVN 2. LVN 2 was informed and acknowledged the finding. X.R 1. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, cited SN visits 1W9 and as needed if there is any change in condition or plan of care. On 3/16/22 at 0940 hours, a joint home visit with LVN 2 was conducted to Patient 3's home. Review of the patient's home folder provided by the HHA showed no documented evidence of the written instructions outlining the name and contact information of the HHA's clinical manager. On 3/16/22 at 1025 hours, an interview and concurrent clinical record review was conducted with LVN 2. LVN 2 was informed and acknowledged the finding. M. A. Bon 2. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22 and 3/6/22 to 5/4/22. The POC, for the certification period from, cited SN visits 1W9 and as needed if there is any change in condition. The POC also cited CHHA visits 1W4. A joint home visit with CHHA was conducted on 3/17/21 at 1100 hours, to Patient 4's home. The patient was asked for the written instructions outlining the name and contact information of the agency's clinical manager. The patient provided the admission packet. The admission packet includes the contact information of the agency. However, the contact information failed to include the written instructions outlining the name and contact information of the agency's clinical manager. On 3/17/22 at 1200 hours, the CHHA was asked if the name and contact information of the agency's clinical manager was written in the admission packet. The CHHA verified the contact information of the agency's clinical manager was not provided. On 3/22/22 at 0934 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the finding.

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 document review, the agency failed to ensure their Covid- 19 Vaccination P&P included at least weekly testing for unvaccinated staff. This created the potential risk of not meeting the health and safety needs of their staff and patient population. Findings: Review of the QSO- 22- 07 showed the HHA's P&Ps must have a process for ensuring those staff who have been granted an exemption or accommodation as authorized by law, adhere to additional precautions that are intended to mitigate the spread of Covid-19. Actions or job modifications an agency can implement to potentially reduce the risk of Covid-19 transmission including requiring at least weekly testing for exempted staff and staff who have not completed their primary vaccination series, until regulatory requirements are met. Review of the agency's Summary Covid-19 Vaccination/ Declination- Employees showed the agency had one employee who was medically exempt from the Covid- 19 vaccination. Further review of the employee's health record showed the employee was tested monthly, starting from January 2021. Review of the agency's P&P titled Covid- 19 Vaccination dated 3/7/22, showed the staff who are not yet fully vaccinated, or who have been granted an exemption or accommodations as authorized by law, or who have a temporary delay, must adhere to additional precautions. The actions or job modifications that may be implemented to support risk reduction of Covid-19 transmission included requiring at least monthly testing for exempted staff who have not completed their primary vaccination series instead of at least weekly testing as outlined in the QSO-22-07. On 3/117/22 at 1510 hours, an interview and concurrent document review was conducted with Office Manager. The Office Manager was informed and acknowledged the finding.

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, clinical record review, and agency P&P review, the agency failed to ensure the skilled professionals provided care and services in accordance with the POC for four of the seven sampled patients (Patients 1, 2, 4, and 6), creating the risk of not providing appropriate, consistent, and quality care to the patient. Findings: The agency's P&P titled Plan of Care - CMS #485 and Physicians Order revised march 2019 showed the skilled nursing and other home health services will be in accordance with the plan of care based on the patient's diagnosis and assessment of immediate and long range needs and resources. 1. Review of Patient 1's closed clinical record was initiated on 3/15/22. The clinical record showed the SOC was 6/26/21. The patient was certified for home health services during the certification periods from 6/26/21 to 8/24/21. a. The POC, for the certification period from 6/26/21 to 8/24/21, cited SN visit 1W1, 2W2, 1W6 and PRN visits to perform comprehensive observation and assessment of all body system. The POC also showed SN to assess for signs and symptoms of depression such as anorexia, weight loss, reduction of activity, restlessness and severe anxiety that may interfere with the ability to function, sleep, eat and enjoy life. Review of the SN notes dated 6/30, 7/2, and 7/23/21, showed the SN had performed body system assessment. However, there was no documented evidence the pedal pulses, edema and capillary refills were assessed. In addition, there was no documented evidence the patient's appetite and weight were assessed to determine if the patient had signs and symptoms of depression as cited in the POC. On 3/22/22 at 1102 hours, an interview with concurrent closed record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if the SN needed to assess the patients appetite and weight as part of the signs and symptoms depression as ordered in the POC. The DPCS/Administrator stated yes, it should be assessed. The DPCS/Administrator was informed and acknowledged the findings. b. The POC, for the certification period from 6/26/21 to 8/24/21, cited CHHA visit 2W9 to assist with hygiene/grooming and repositioning. However, there was no documented evidence of CHHA visits. On 3/22/22 at 1102 hours, an interview with concurrent closed record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if the CHHA had visited the patient as ordered in the POC. The DPCS/Administrator stated she needed to double check. On 3/22/23 at 1518 hours, LVN 1/Case Manager provided a missed visit document to address the CHHA needs. The LVN/Case manager stated the patient's caregiver would take care of the patient and only notified the HHA if there was any problem. However, there was no documented evidence the physician had ordered to cancel CHHA services. The DPCS/Administrator and LVN 1/Case manager were informed and acknowledged the finding. c. The POC, for the certification period from 6/26/21 to 8/24/21, cited PT evaluation. Review of the initial comprehensive assessment dated 6/26/22 , showed a referral for PT. However, the PT evaluated the patient on 7/18/21, more than three weeks after the referral. On 3/22/22 at 1128 hours, an interview with concurrent closed record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked as to the timeframe for the PT to perform the evaluation as ordered. The DPCS/Administrator stated they needed to perform the evaluation within 48 hours from the referral order. The DPCS/Administrator was informed of the finding. The DPCS/Administrator stated she needed to double check if there was a documentation. On 3/22/22 at 1518 hours, LVN 1/Case manager provided a communication report from the PT dated 6/28/21. The communication report showed a tentative visit schedule only. The DPCS/Administrator and LVN 1/Case Manager were informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22, and 3/6/22 to 5/4/22. a. Review of the Physician's Order dated 12/23/21, showed a referral for PT with medical equipment and front wheel walker. However, there was no documented evidence the PT had visited Patient 4. On 3/22/22 at 0948 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if the patient was referred to the PT as ordered. The DPCS/Administrator stated the patient refused PT services. However, there was no documented evidence the physician had ordered to cancel PT services. The DPCS/Administrator acknowledged the finding. b. The POC, for the certification period from 1/5/22 to 3/5/22, cited SN visits 2W4, 1W5 and PRN visits for comprehensive observation and assessment of all body system with emphasis on cardiovascular, respiratory, musculoskeletal, integumentary, urinary and digestive system. The POC also cited SN to perform wound care as ordered: cleanse the lower abdomen wound with normal saline, pat dry, apply a xeroform dressing and cover with a dry dressing; and change dressing daily and as needed for dislodgment or soiling for 4 weeks. Review of the SN note dated 1/18/22, failed to show documented evidenced the SN had performed wound care and treatment as ordered in the POC. In addition, for Week 3 (1/9 to 2/5/22) , the SN had visited the patient once on 1/13/22, instead of two times a week as cited in the POC. d. The POC, for the certification period from 1/5/22 to 3/5/22, showed the patient primary diagnosis was encounter for other artificial openings of the urinary tract. The POC cited SN to teach disease processes and management, preventive measure, signs and symptoms of the complications/exacerbation with emphasis on artificial openings of the urinary tract. The POC also showed SN to instruct patient about the suprapubic catheter care: always wash hands with soap and water before and after handling the catheter, make sure that the catheter tubing does not get twisted or kinked, and that urine is flowing out of the catheter into the urine collection bag, keep the urine collection bag below the level of the bladder, clean the bag every other day after removing it from the catheter, and use another catheter while cleaning the bag. Review of the SN notes dated 2/24, 2/17, 2/15, 2/10, 2/3, 1/27, 1/25, 1/22, 1/19, 1/18, 1/13 and 1/6/22 , showed the SN had performed genitourinary assessment. However, there was no documented evidence the SN had assessed the patient's artificial opening of the urinary tract; and instructed the patient in performing catheter care as cited in the POC. e. The POC, for the certification period from 1/5/22 to 3/5/22, also showed SN to assess/monitor/instruct bleeding precautions and symptoms of bleeding such as bright red/coffee ground emesis, melena, hypotension, weakness, dizziness and rapid pulse. The POC also cited SN to provide handouts on the disease processes. The POC also included the patient's other diagnoses which included unspecified atrial fibrillation and generalized muscle weakness; and a medications for atrial fibrillation and bleeding. * Review of the SN notes dated 2/24, 2/17, 2/15, 2/10, 2/3, 1/27, 1/25, 1/22, 1/19, 1/18, 1/13 and 1/6/22, showed the SN had performed body system assessment. However, there was no documented evidence the SN had assessed the pedal pulses, edema, and capillary refills; and provided instructions related to bleeding as cited in the POC. * Review of the SN notes dated, 2/15, 2/10, 2/3, 1/27, 1/25, 1/22, 1/19, 1/18,/19 and 1/13/22, showed the SN had performed musculoskeletal assessment. However, there was no documented evidence SN had assessed the patient's gait and strength and provided handouts related to the disease process as cited in the POC. On 3/22/22 at 0948 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the findings. 3. Review of Patient 2's closed clinical record showed the SOC was 10/12/21. The clinical record showed the patient received home health services during the certification period from 12/11/21 to 2/8/22. The POC, for the certification period from 12/11/21 to 2/8/22, showed to perform and assess the vital signs including temperature, pulse rate, respiratory rate, blood pressure checks, and oxygen saturation level every visit. Review of the Comprehensive Discharge form dated 10/12/21, failed to show documented evidence the oxygen saturation level was assessed and evaluated as cited in the POC. On 3/22/22 at 0843 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and verified the findings. 4. Review of Patient 6's closed clinical record was initiated on 3/16/22. The clinical record showed the SOC was 11/24/21. The patient was certified for home health services during the certification periods from 11/24/21 to 1/22/22, and 1/23/22 to 3/23/22. a. The POC, for the certification period from 11/24/21 to 1/22/22, cited diagnoses of hypertensive hear disease with heart failure, and diabetes mellitus with diabetic chronic kidney disease. The POC also cited SN to notify the physician of any sudden change in status. Review of Patient 6's physician's order dated 1/13/22, showed to provide wound care as follows: - Cleanse the right ankle unstageable wound with normal saline, pat dry, apply triple antibiotic, apply a sterile gauze and kerlix roll, and secure with tape.; and change dressing daily and as needed for soiling or dislodgement. The PCG will perform wound care on non SN visit days - Cleanse the left foot unstageable wound with normal saline, pat to dry, apply triple antibiotic, apply a sterile gauze, and kerlix roll and secure with tape; and change dressing daily and as needed for soiling or dislodgement. The PCG will perform wound care on non SN visit days Review of Patient 6's physician's order dated 1/20/22, showed to provide wound care as follows: - Cleanse the right ankle unstageable wound with normal saline, pat dry, apply Mupirocin ointment to wound bed, cover with calcium alginate, apply a sterile gauze and wrap. The PCG will resume wound care on non SN visit days. - Continue same treatment with the left foot wound as ordered. Review of the Patient of the recertification order dated 1/20/22, showed the following wound treatments: - Cleanse the right ankle pressure ulcer with normal saline, pat dry, apply mupirocin ointment on wound bed, cover with calcium alginate, apply a sterile gauze, wrap with kerlix wrap, and secure with tape; and change dressing daily and as needed for soiling/dislodgment. The PCG will perform wound care on non SN visit days. - Cleanse the left foot non pressure ulcer with normal saline, pat dry, apply triple antibiotic, cover with a sterile gauze, apply kerlix roll, secure with tape; and change dressing daily and as needed for soiling or dislodgement. The PCG will perform wound care on non SN visit days. Review of the SN notes dated 1/13/22, showed the SN had performed wound treatment and assessment. The SN noted the right ankle wound measured 3 cm x 3 cm (length x width); and right lateral heel unstageable measured 1.5 cm x 1.5 cm. Further review of the SN note showed the communications were made to the supervisor and physician regarding the right ankle and left foot wounds; and the patient/caregiver teachings and instructions provided for wound care for the unstageable right ankle and unstageable wound to the left foot. In addition, the wound care notes showed wound photos for the right ankle and right heel wounds. No images of the left foot were documented. Review of the Recertification OASIS dated 1/20/22, showed Patient 6 had one Stage 2 unhealed pressure ulcers, and one Stage 3 unhealed pressure ulcers. Further review of the OASIS showed a wound assessment and photograph of the right ankle as a pressure ulcer Stage 3, and a wound assessment and photograph of the right heel as a Stage 2 pressure ulcer. However, further review of the clinical record failed to show documented evidence the physician was notified of the change of condition to Patient 6's wounds. Review of the SN notes dated 1/27, 2/5, and 2/10/22, showed the SN had performed wound treatment and assessment. The SN documented the right ankle wound as a Stage 3 pressure ulcer, and left foot non pressure wound. However, there was no documented evidence the physician was notified of the change of condition to Patient 6's wounds. On 3/22/22 at 0956 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for six of seven sampled patients (Patients 2, 3, 4, 5, 6, and 7), creating the increased risk of substandard healthcare outcomes to this patient. Findings: 1. Review of Patient 2's closed clinical record showed the SOC was 10/12/21. The closed clinical record showed the patient received home health services during the certification period from 12/11/21 to 2/8/22. a. The POC, for the certification period form 12/11/21 to 2/8/22, showed Patient 2’s documented nutritional requirement was “regular/soft thin liquid.” Review of the Recertification Order form dated 12/6/21, showed Patient 2’s documented nutritional requirement was “regular/soft thin liquid.” However, review of the Comprehensive Discharge assessment dated 2/5/22, showed the SN had checked the boxes next to no added salt, low sodium, and low fat as Patient 2’s nutritional requirement. Further review of Patient 2’s closed clinical record revealed no documented evidence the physician made any changes to the patient’s nutritional requirement. On 3/22/22 at 0843 hours, an interview and concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager verified the findings. b. Review of Patient 2’s Skilled Nurse Clinical Notes electronically signed on 1/19/22, showed the SN had assessed the patient’s cardiovascular system. The SN had checked the box next to “WNL” meaning the assessment was within normal limits; however, under Observations/Assessments/Problems, the SN had documented the patient had +1 swelling to the bilateral lower extremities. On 3/22/22 at 0849 hours, an interview and concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager verified the findings. 2. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, cited SN visits 1W9 and as needed if there was any change in condition or plan of care. Review of Patient 3’s clinical record showed the SN provided a home visit on 3/9/22; however, the SN failed to submit the clinical documentation showing the assessments and services provided on this date. On 3/22/22 at 0913 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the finding. 3. ,Review of Patient 5's clinical record was initiated on 3/17/22. The clinical record showed the SOC was 2/26/22. The patient was certified for home health services during the certification periods from 2/26/22 to 4/26/22. The POC, for the certification period from 2/26/22 to 4/26/22, showed Patient 5 with diagnoses including seizures, osteoporosis, hemiplegia affecting right dominant side, and gait and mobility abnormalities. Review of Patient 5's PT initial Evaluation dated 3/4/22 showed Patient 5 presented with severe contractures at the right fingers, and weakness was present for the right upper and lower extremities. Review of the comprehensive initial comprehensive assessment dated 2/27/22, showed the following assessments: - Neurological/ Emotional/ Behavioral: weakness to the right upper extremity and right lower extremity; hand grips were equal. - Musculoskeletal: Contracture was blank. Patient 5 had paralysis and right hemiplegia. The patient's gait was unsteady with limited ROM to the right upper extremity and right lower extremities. Review of Patient 5's Skilled Nurse Clinical Notes dated 3/2/22 and 3/5/22, showed a neurological assessment was WNL. The assessment showed the sections for weakness and hand grips were blank. Review of Patient 5's Skilled Nurse Clinical Notes dated 3/12/22, showed the neurological and musculoskeletal assessments were within normal limits. The assessment showed the sections were blank. Further review of the notes showed the cardiovascular section blank. On 3/22/22 at 0930 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case manager. LVN 1/Case manager was informed and acknowledged the above findings. 4.a. Review of Patient 7's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/6/21. The patient was certified for home health services during the certification periods from 12/6/21 to 2/3/22, and 2/4/22 to 4/4/22. The POC, for the certification period from 12/6/21 to 2/3/22, showed showed SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, musculoskeletal, endocrine, urinary, and digestive status. Review of Patient 7's Skilled Nurse Clinical Notes dated 12/17/21, 1/19/22, and 1/26/22, showed Patient 7 was assessed to have 2+ pitting edema to the left and right lower extremities. Further review of the clinical note showed pedal pulses were left blank. Review of Patient 7's Skilled Nurse Clinical Notes dated 1/15/22, showed Patient 7 was assessed to have 2+ edema to the left and right lower extremities. However, there was no documented evidence showing if the edema were pitting or nonpitting. Further review of the clinical note showed the pedal pulses sections were left blank. b. The POC, for the certification period from 2/4/22 to 4/4/22 , showed SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, musculoskeletal, endocrine, urinary, and digestive status. Further review of Patient 7's POC showed the SN to perform and assess vital signs: temperature, pulse rate, respiratory rate, and blood pressure, and oxygen saturation level. Review of Patient 7's Skilled Nurse Clinical Notes dated 2/9/22, showed Patient 7 was assessed to have 1+ pitting edema to the left and right lower extremities. Further review of the clinical note showed the pedal pulses sections were left blank. Review of Patient 7's Skilled Nurse Clinical Notes dated 2/16/22, showed Patient 7 was assessed to have 1+ edema to the left and right lower extremities. However, the clinical note failed to show if the edema was pitting or nonpitting. In addition, the pedal pulses sections were left blank. Review of Patient 7's Skilled Nurse Clinical Notes dated 3/8/22, showed Patient 7's vital signs as follows: pulse rate 18 beats per minute (normal is 60 -100 bpm), oxygen saturation level was left blank, respirations 18 breaths per minute, temperature 96.5 degrees F, and blood pressure 111/52 mmHg. The cardiovascular assessment showed assessment was within normal limits. Further review of the clinical note failed to show a note the physician was notified of the abnormal vital signs, and failed to show the nurses' actions in response to the abnormal vital signs. On 3/22/22 at 0841 hours, an interview was conducted with LVN 3. LVN 3 was informed and acknowledged the above findings. 5. Review of Patient 6's clinical record was initiated on 3/16/22. The clinical record showed the SOC was 11/24/21. The patient was certified for home health services during the certification periods from 1/23/22 to 3/23/22, and 11/24/21 to 1/22/22. The POC, for the certification period from 1/23/22 to 3/23/22, showed SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, musculoskeletal, endocrine, urinary, and digestive status. Review of the Skilled Nurse Clinical Notes dated 2/5, 2/10, and 2/18/22, showed the patient reported no issues with performing in-home peritoneal dialysis. However, further review of the clinical note failed to show the SN completed a genitourinary assessment or an assessment of the patient's PD catheter. On 3/22/22 at 0956 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings. 6. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22, and 3/6/22 to 5/4/22. Review of the POC for the certification period from 1/5/22 to 3/5/22, cited for SN visit 2W4, 1W5, and PRN visits. The POC also cited SN to perform comprehensive observation and assessment of all the body system with emphasis on cardiovascular, respiratory, musculoskeletal, integumentary, urinary and digestive system. The POC included other diagnoses includes presence of cardiac pacemaker. The POC also showed the list of medications. The medication includes amiodarone for atrial fibrillation. a. Review of the initial comprehensive assessment dated 1/5/22, showed the RN had performed body system assessment. The assessment included cardiovascular system, integumentary and genitourinary system. The assessment also included the patient primary diagnosis documented as an encounter for other artificial openings of the urinary tract. The patient's other diagnoses included unspecified atrial fibrillation, benign prostatic hyperplasia with lower urinary tract symptoms. * Review of the cardiovascular system assessment showed the RN checked the box next to WNL, meaning within normal limits which was inconsistent. * The RN failed to document the patients pacemaker as identified in the patients other diagnoses. * Review of the genitourinary system assessment showed the patient had the 18 french suprapubic catheter. However, the RN checked the box for WNL meaning within normal limits which was inconsistent. b. Review of the SN notes dated 1/13, 1/18, 1/19, 1/22, 1/25, 1/27, 2/2, 2/15, 2/17, and 2/24/22, showed the SN had performed genitourinary system. However, the SN checked the box for WNL meaning within normal limits which was inconsistent. c. Review of the SN notes dated 1/19, 1/13, and 1/6/22, showed the SN had performed integumentary system assessment. On the section of the narrative note, the SN documented a wound treatment and dressing change was performed to the patient's wound in the lower abdomen. However, the box for integumentary system was checked as WNL meaning within normal limits which was inconsistent. d. Review of the recertification OASIS dated 3/2/22, showed the RN had performed a body system assessment. The assessment included the integumentary system. * However, review of the integumentary system showed the RN checked the box for WNL meaning within normal limits which was inconsistent. On 3/22/22 at 0847 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the findings.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the written agreements for the contracted medical staffs (Medical Director, Associate Medical Directors 1 and 2, and Contracted Providers 1 and 2) providing medical services and rehabilitation company (Companies 1, 2, 3, and 4) providing PT, OT, ST, RD and MSW services included the role of the contracted providers in the supervision and evaluation of the care and services provided, patient assessment, the development, review, and revision of POCs, patient care conferences, scheduling of visits or hours, discharge planning, submission of documentation of services provided to the agency, and that agreements will be reviewed and revised as necessary. In addition, the agency failed to ensure the health assessments for two of eight employees were within six months prior to or within 15 days of hire. These failures created the risk for not providing necessary services to the patients. Findings: 1. According to California Code of Regulations, Title 22, Section 474719 titled Services Arranged by Agreement, when a service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the following: The role, if any, of the agency and the contracted individual or agency in the patient care conferences. The agreements shall be reviewed and revised as necessary. a. Review of the written agreement between the agency and Company 1 providing PT, OT, ST, RD and MSW services was conducted on 3/17/22. The written agreement failed to include the rights and responsibilities of the agency or contracted provider in the patient care conferences. The agreements shall be reviewed and revised as necessary.b. Review of the written agreement between the agency and the Medical Director providing medical services was conducted on 3/17/22. The written agreement failed to include the agreements shall be reviewed and revised as necessary. c. Review of the written agreement between the agency and the Associate Medical Director 1 providing medical services was conducted on 3/17/22. The written agreement failed to include the agreements shall be reviewed and revised as necessary. d. Review of the written agreement between the agency and the Associate Medical Director 2 providing medical services was conducted on 3/17/22. The written agreement failed to include the agreements shall be reviewed and revised as necessary. On 3/17/22 at 1158 hours, LVN 1/Case Manager was informed of the findings. LVN 1/Case Manager reviewed the contracts and verified the findings. 2. According to Title 22, Division 5, Chapter 6, Article 4, 74719 Services Arranged by Agreement, when a service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include the rights and responsibilities of the agency or individual providing services and of the contraction agency in the coordination, supervision and evaluation of care and services provided; patient assessment; the development, review, and revision of POCs; patient care conferences; scheduling of visits or hours; discharge planning; submission of documentation of services provided to the agency; and those agreements will be reviewed and revised as necessary. Review of the written agreements between the agency, Companies 2, 3, and 4, and Contracted Providers 1 and 2 providing pharmacy, social worker, physical therapy, licensed nurses, CHHAs, occupational therapy, and speech therapy services were conducted on 3/17/22. a. The written agreements with Companies 2, 3, and 4, and Contracted Providers 1 and 2 did not include a statement showing the agreements will be reviewed and revised as necessary. On 3/21/22 at 1345 hours, an interview and concurrent document review was conducted with the Office Manager and HR Coordinator. The Office Manager and HR Coordinator verified the findings. b. Review of the written agreement between the agency and Contracted Provider 2 providing physical therapy services was conducted on 3/17/22. The written agreement with Contracted Provider 2 dated 10/27/21, did not include the role of the agency and Contracted Provider 2 in the discharge planning process. On 3/22/22 at 0948 hours, an interview and concurrent document review was conducted with the HR Coordinator. The HR Coordinator verified the findings. c. Review of the written agreement between the agency and Company 3 providing skilled nursing and CHHA services was conducted on 3/17/22. The written agreement with Company 3 dated 7/15/21, did not include the rights and responsibilities of the agency or individual providing services and of the contraction agency in the supervision and evaluation of care and services provided; patient assessment; the development, review, and revision of POCs; patient care conferences; scheduling of visits or hours; discharge planning; and submission of documentation of services provided to the agency. On 3/22/22 at 0956 hours, an interview and concurrent document review was conducted with the Office Manager. The Office Manager verified the findings. 3. According to Title 22, Division 5, Chapter 6, Article 4, 74723 Employee’s Health Examination and Health Records, all agencies shall require health assessments and maintain health records for employees with direct patient contact. A written health assessment of each employee who has direct patient contact shall be performed within six months prior to employment or within 15 days of assuming employment with the agency. Review of the personnel files was conducted on 3/17/22. The following was identified: - RN 1’s personnel file showed the hire date was 5/15/21; however, the written health assessment for RN 1 was completed on 7/7/21. - LVN 4’s personnel file showed the hire date was 1/12/21; however, the written health assessment for LVN 4 was completed on 4/29/21. On 3/22/22 at 0946 hours, an interview and concurrent document review was conducted with the HR Coordinator. The HR Coordinator was informed and acknowledged the findings.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on interview and clinical record and document review, the agency failed to ensure the CLIA waiver certificate was current when conducting the blood glucose testing for two of seven sampled resident (Patient 6 and 7), creating the risk of not meeting the regulatory standards related to laboratory testing. On 3/15/22 at 0945 hours, an entrance conference was conducted with LVN 1/Case manager. LVN1/Case manager was asked to provide the agency's CLIA certificate of waiver. Review of the agency's CLIA certificate of waiver showed the effective date was 10/02/19, and the expiration date was on 10/01/21. On 3/18/22 at 0843 hours, an interview was conducted with the Office Manger and LVN 1/Case manager. The Office Manager stated they overlooked the agency's CLIA certificate of waiver had expired on 10/1/21. The Office Manager stated the renewal application and payment were sent on 2/22/22. LVN 1/Case manager stated they had not received the new CLIA certificate of waiver for this year. They were asked if the agency provided laboratory tests even the CLIA certificate was expired. The LVN/Case manager stated yes, they still provided laboratory testing as ordered such as CBC, CMP, UA and C&S tests. They sent the order to the contracted laboratory and they would schedule the visit to the patients home. They were further asked if they performed blood sugar checks to the patients who was diabetic. LVN 1/Case manager stated yes, it should have been in the care plan and they checked the blood sugar every SN visit unless the patient had checked the blood sugar or refused the random blood sugar check. LVN 1/Case manager continued stating, the agency followed the parameters as to when to notify the physician and would provide the orders if needed. They were further asked as to how many diabetic patients the agency had. LVN 1/Case manager stated they had four patients with diabetes and checked the blood sugar every visit as ordered and as needed. Review of two clinical records for Patients 6 and 7 showed an order to perform the blood glucose testing. However, the agency's CLIA waiver certificate was not current. On 3/22/22 at 1142 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator and LVN 1/Case manager. They were informed and acknowledged the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency's Administrator failed to be responsible for the day to day operations related the development P&P for wound assessment and weight monitoring; and failed to maintain the current CLIA certificate of waiver. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Review of the agency's Job Description for Administrator showed the Administrator ensures the quality and safe delivery of home health care services, coordinates services that reflect the agency's philosophy and standard of care, plans, develops, implements and evaluates agency services, programs and activities and responsible for all day to day operations of the agency. The responsibilities included directing the agency's ongoing functions, develops, implements and evaluates policies and procedures and records, evaluating services and programs and maintains compliance with the applicable federal, state, accrediting bodies and local rules and regulations. 1. Review of Patient 4's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 1/5/22. The patient was certified for home health services during the certification periods from 1/5/22 to 3/5/22 and 3/6/22 to 5/4/22. a. The POC, for the certification period from 1/5/22 to 3/5/22, showed the SN to perform wound care in the lower abdomen as follows: cleanse with NS, pat dry, apply a xeroform dressing, and cover with a dry dressing; and change dressing daily and as needed for dislodgement or soiling for four weeks. The PCG will perform wound care for non SN visit days. Review of the initial comprehensive assessment dated 1/5/22, showed the RN had performed wound assessment and treatment to the patient's mid lower abdominal wound. The assessment also included a wound photograph. However, review of the clinical record failed to show a follow-up wound photographs were taken and the wound assessment. On 3/17/22 at 1400 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if a wound photograph was taken. The DPCS/Administrator stated yes, a wound photograph together with wound assessment were completed on the initial comprehensive assessment. She was further asked as to the frequency of wound assessment and wound photographs. The DPCS/Administrator stated the wound photographs were taken every two weeks together with the complete wound assessment. She further stated they followed the agency's wound manual for photographs and assessment and they did not have a P&P specific for for wound assessment and photographs. On 3/22/22 at 1148 hours, a follow-up interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was informed and acknowledged the findings. b. The POC, for the certification period from 3/6/22 to 5/4/22, showed the patient's primary diagnosis was hypertensive heart disease without heart failure. The medications included furosemide 20 mg one tablet Q12 hours for congestive heart failure. However, review of the recertification OASIS dated 3/2/22, failed to show the RN had taken the patients weight as part of the comprehensive assessment. In addition, review of the SN notes dated 3/10/22, failed to show documented evidence the SN had taken the patient's weight. On 3/22/220 at 0841 hours, an interview with concurrent clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked if the patient's weight needed to be documented. The DPCS/Administrator reviewed the clinical record and stated the RN missed the weight on the initial comprehensive assessment. The DPCS was further asked as to the frequency of weight monitoring. She stated weight should be taken every initial comprehensive and recertification assessment and depending on the physician's order. On 3/22/22 at 1148 hours, the DPCS/Administrator was asked if they have a P&P related to weight monitoring. The DPCS/Administrator stated no P&P for weight and only followed the physicians order. She was informed and acknowledged the findings. 2. The agency's CLIA certificate waiver had expired on 10/1/21. Cross reference to G862.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview, clinical record review, and agency P&P review, the agency failed to ensure the clinical record was completed in a timely manner for two of seven sampled patients (Patients 1 and 3), creating the risk of not appropriately authenticating the contents of the patient's clinical record. 1. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, showed the RN electronically signed and dated the POC on 2/18/22. However, there was no documented evidence of the physician’s signature. On 3/22/22 at 0905 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case manager. LVN 1/Case manager was informed and acknowledged the finding. Findings: According to the California Code of Regulations, Title 22, Section 74701(a), no medication or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient's attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice within 30 working days. The agency P&P titled Physician Orders and Tracking System revised October 2017, showed the the physician orders are signed and returned to the agency for placement in the patients medical record within 30 to 60 days of the day they are written. The procedure includes all physician orders should be sent from the office the day they arrive or the day they are prepared. The original copy of the order is sent to the physician for signature. A copy will be maintained on the patients medical record until the signed order is returned. When signed orders are received in the office, the unsigned copies in the tracking file and on the patients medical record are destroyed. The signed copy then goes into the patients medical record. 1. Review of Patient 1's closed clinical record was initiated on 3/15/22. The clinical record showed the SOC was 6/26/21. The patient was certified for home health services during the certification periods from 6/26/21 to 8/24/21. The patient was discharged on 8/24/21. The POC, for the certification period from 6/26/21 to 8/24/21, showed the RN received the verbal SOC on 6/26/22. The POC also showed the physicians signed and dated the POC on 7/1/21. Review of the Physician Orders showed the following orders were read back and verified by an RN. - Notification and Care Coordination dated 7/2/21 at 1400 hours, 7/3/21 at 1800 hours, 7/19/21 at 0900 hours, 7/23/21 at 1530 hours, 7/30/21 at 1600 hours, 7/31/21 at 1445 hours and 8/2/21 at 1630 hours. - Resumption of Care Order dated 7/15/21 at 1900 hours. - Missed visit order dated 8/13/21 at 1630 hours and 8/19/21 at 1600 hours. - Discharge order dated 8/24/21 at 1330 hours. However, the orders failed to show the date, time and the physicians signature who provided the verbal orders. On 3/22/21 at 1102 hours, an interview with concurrent closed clinical record review was conducted with the DPCS/Administrator. The DPCS/Administrator was asked as to the timeline for the physician signature. The DPCS/Administrator stated, the physician should sign the orders within 30 days. The DPCS/Administrator reviewed the clinical record and provided another copies of the physician orders with the corresponding signature and date. She further stated the verbal orders were sent to the physicians for signatures. The DPCS/ Administrator was further asked if all the physician orders with signature has been provided. The DPCS/ Administrator replied yes, the copies were provided. The DPCS/Administrator was informed and acknowledged the findings. X. R 2. Review of Patient 3's clinical record was initiated on 3/15/22. The clinical record showed the SOC was 12/24/21. The patient was certified for home health services during the certification period from 2/22/22 to 4/22/22. The POC, for the certification period from 2/22/22 to 4/22/22, showed the RN electronically signed and dated the POC on 2/18/22. However, there was no documented evidence of the physician’s signature. On 3/22/22 at 0905 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case manager. LVN 1/Case manager was informed and acknowledged the finding.