Every finding on record at La Global Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted from 8/15/2024 to 8/17/2024. Complaint Number: 104407 Active Patients: 51 Sample Size - 12 Home Visits - 3 On 8/17/2024, at 5:08 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Director of Patient Care Services (DPCS) and Office Manager (OM) related to the home health agency (HHA) failure to ensure the patient clinical records of four sampled patients (Patient 9, Patient 10, Patient 11, and Patient 12) included routine visit clinical notes that reflected the patient's current health status. The non-compliance resulted in incomplete clinical records that does not reflect patients' current condition and needs which likely to cause unidentified needs, serious injury, harm, impairment, or death to a patient. As a result, Patient 9, Patient 10, Patient 11, and Patient 12 did not have completed clinical records that could potentially affect the patients’ care and services and could lead to potential hospitalization or death. On 8/17/2024, at 5:30 p.m., the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team completed the survey tasks and conducted an exit conference, with the DPCS, with the IJ situation not removed. On 8/24/2024 the HHA submitted an IJ removal plan. The IJ removal plan was reviewed and accepted on 8/28/2024 as follows: Corrective and Preventative Action Plan: The agency took the following corrective and preventive measures to enhance the current process of ensuring patients receive care according to their personalized care plans. Specifically, skilled nursing notes and having all medical records available for review upon request. On 08/19/2024, a meeting was held between the administration and all nursing staff. The home health agency discussed and implemented all skilled nursing notes for the past and current active patients that the DPCS, office manager has access to the locked medical records cabinet. Due to the survey being conducted on the weekend the office manager and DPCS were unable to gain access to patient 9, 10, 11 and 12’s clinical records that were locked in a file cabinet that the medical records coordinator who was off that weekend had the key to. Which prevented the HHA from supplying the skilled nursing clinical notes to the survey team as requested. As of 08/19/2024, The home health agency will ensure that all patients charts, and clinical notes are stilled locked in the cabinet. However, besides the medical records coordinator having the key/access to the cabinet, the office manager and DPCS has been given access to ensure all active patients clinical records are available for review when requested and home health agency is in compliance with the state regulations. On 08/19/2024, Patient 9, 10, 11 and 12’s clinical record notes were retrieved from the locked cabinet. The DPCS and office manager were given keys/access. The clinical notes were reviewed by DPCS and QAPI staff. All active patient charts were audited to ensure 100% compliance. In services to all staff on the policy and procedures of completing clinical notes and submitting them within 7 days of visit was conducted. To ensure up to date clinical notes which reflect the patients skilled need for home health services along with patients signed route sheet ensuring all clinical notes are appropriately authenticated with signature and date. The DPCS will conduct monthly focused chart audits to ensure compliance, the findings will be reported to the Performance Improvement Committee and Governing Body Quarterly during QAPI committee meetings and annually as part o the annual organizations evaluation. As of 08/22/2024, all clinical notes for patient 9, patient 10, patient 11, patient 12 and all active patients note submission is 100%. The home health agency will conduct a review every week for 3 months to assess compliance with the policy. The home health agency will continuously monitor, and update policies and procedures based on ongoing audits and feedback to ensure sustained complianee and adherence in clinical note documentation practices. On 08/19/2024, the agency conducted 100% record review of all active patients (47) to assess how many patients were affected by the deficient practices of not having clinical notes in the patient’s medical record. The agency recognized the active patients that were all in compliance. Staff did not have access to the locked medical record cabinet. At the time of survey, there were 51 active patients. Since the survey, 4 patients have been discharged due to goals being met. At this time, 47 patients have current and up to date notes in the medical record (please see attached documents for specific patients completed). Therefor the current compliance rate is 100%. By implementing this corrective and preventative action plan, the home health agency aims to improve the efficiency and compliance of completed notes in the patients medical records, thereby enhancing the patients care through timely access to comprehensive medical records. On 8/29/2024 the survey team conducted an onsite verification of the IJ removal plan and the IJ was removed on 8/29/2024 at 1 pm., in the presence of the Office Manager/CEO. The following Conditions of Participation were not met: 484.55 Comprehensive Assessment of Patients. 484.110 Clinical records

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to assess the patient's continuing need for home care services for four of 12 sampled patients (Patient 9, Patient 10, Patient 11 and Patient 12). This deficient practice resulted in the provision of an unnecessary home health services to the patients who did not need skilled nursing services. (Refer to G532). 2. The HHA failed to maintain an accurate, current medication profile for two of seven patients (Patients 1 and Patient 5). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. (Refer to G536). 3. The HHA failed to ensure the skilled nurse (SN) assessed, verified, and documented the update of the comprehensive assessment for the need for blood sugar check for one of twelve sampled patients (Patient 4). (Refer to G544). The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for home care services for four of 12 sampled patients (Patient 9, Patient 10, Patient 11 and Patient 12). This deficient practice resulted in the provision of an unnecessary home health services to the patients who did not need skilled nursing services. a. During a review of Patient 9’s Patient Information sheet indicated Patient 9's start of care (SOC) was 5/30/2024, with diagnosis that included spondylosis (age related wear and tear of the spinal disk). During a review of Patient 9's Home Health Certification and Plan of Care for the certification period starting from 5/30/2024 to 7/28/2024, indicated an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks for comprehensive skilled nursing assessment, observation and evaluation of all body systems, perform every visits vital signs (measures the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain assessment, and evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. Patient 9's Home Health Certification and Plan of Care indicated that the goal included patient’s skin integrity would remain intact, would demonstrate competence in following medical regimen, and would be free of any falls, injuries, and hospitalizations. Patient 9's Home Health Certification and Plan of Care included a discharge planning that indicated to discharge patient when medical condition stabilizes and when maximum functional potential is reached. During a review of Patient 9's clinical records (in general) indicated there was no documented evidence that Patient 9 had wounds, had no falls or hospitalization, undergoing rehabilitation treatment, there was no evidence of the need for skilled nursing services to continue. There was no evidence that Patient 9 eligible to be re-certified for another 60 days of continuous skilled nursing services. During a concurrent interview and record review, on 8/17/2024 at 1:45 p.m., with the agency’s Director of Patient Care Services (DPCS), the DPCS stated Patient 9 had no recent hospitalization, no falls, no wound care, and have no rehabilitation services performed. DPCS stated that based on the patient assessment and visit notes, her goals have been met, and should have been discharged. b. During a review of Patient 10’s Patient Information sheet indicated Patient 10's start of care date (SOC) was 2/1/2024, with diagnosis that included idiopathic neuropathy (a disorder that affects the peripheral nervous system). During a review of Patient 10's Home Health Certification and Plan of Care for the certification period starting from 5/31/2024 to 7/29/2024, Patient 10's Home Health Certification and Plan of Care indicated an order for the SN frequency of visits of once a week for nine weeks, for comprehensive skilled nursing assessment, observation and evaluation of all body systems, perform every visits vital signs, pain assessment, and evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. Patient 10's Home Health Certification and Plan of Care indicated that the goal included patient’s skin integrity would remain intact, would demonstrate competence in following medical regimen, and would be free of any falls, injuries, and hospitalizations. Patient 10's discharge planning indicated to discharge patient when medical condition stabilizes and when maximum functional potential is reached. During a telephone interview, on 8/16/2024 at 11 a.m. with Patient 10, Patient 10 stated that he was independent with his care, able to visit his physician regularly, had no falls, no wounds, and no hospitalization. During a review of Patient 10's clinical record (in general) indicated there was no documented evidence Patient 10 had any wounds, had any falls or hospitalization, undergoing rehabilitation treatment, nor any evidence of the need for skilled nursing services to continue. There was no evidence that Patient 10 was eligible to be re-certified for another 60 days of continuous skilled nursing services. During a concurrent interview and record review, on 8/17/2024 at 2 p.m., with the agency’s DPCS, the DPCS stated Patient 10 had no recent hospitalization, no falls, no wound care, and have no rehabilitation services performed. DPCS stated that based on the patient assessment and visit notes, her goals have been met, and should have been discharged. c. During a review of Patient 11’s Patient Information sheet indicated Patient 11's start of care date was 1/6/2024, with diagnosis that included hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 11's Home Health Certification and Plan of Care for the certification period starting from 5/5/2024 to 7/3//2024, included an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks , for comprehensive skilled nursing assessment, observation and evaluation of all body systems, perform every visits vital signs, pain assessment, and evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. Patient 11's Home Health Certification and Plan of Care indicated that the goal included patient’s skin integrity would remain intact, patient/PCG would demonstrate competence in following medical regimen, and would be free of any falls, injuries, and hospitalizations. Patient 11's discharge planning indicated to discharge patient when medical condition stabilizes and when maximum functional potential is reached. During a review of Patient 11's clinical record (in general) indicated there was no documented evidence Patient 11 had any wounds, had any falls or hospitalization, undergoing rehabilitation treatment, nor any evidence of the need for skilled nursing services to continue. There was no evidence that Patient 11 was eligible to be re-certified for another 60 days of continuous skilled nursing services. During a concurrent interview and record review, on 8/17/2024 at 2:05 p.m., with the agency’s DPCS, the DPCS stated Patient 11 had no recent hospitalization, no falls, no wound care, and have no rehabilitation services performed. DPCS stated that based on the patient assessment and visit notes, her goals have been met, and should have been discharged. d. During a review of Patient 12’s Patient Information sheet indicated Patient 12's start of care date was 5/25/2024, with diagnosis that included idiopathic neuropathy (a disorder that affects the peripheral nervous system) During a review of Patient 12's Home Health Certification and Plan of Care for the certification period starting from 5/25/2024 to 7/23/2024, indicated an order for the skilled nurse frequency of visits of once a week for nine weeks, for comprehensive skilled nursing assessment, observation and evaluation of all body systems, perform every visits vital signs, pain assessment, and evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. Patient 12's Home Health Certification and Plan of Care indicated that the goal indicated that patient’s skin integrity would remain intact, patient/PCG would demonstrate competence in following medical regimen, and would be free of any falls, injuries, and hospitalizations. Patient 12's discharge planning indicated to discharge patient when medical condition stabilizes and when maximum functional potential is reached. During a review of Patient 12's clinical record (in general) has no documented evidence that Patient 12 had wounds, had falls or hospitalization, undergoing rehabilitation treatment, nor any evidence of the need for skilled nursing services to continue. However, Patient 12 was re-certified for another 60 days of continuous skilled nursing services. During a concurrent interview and record review, on 8/17/2024 at 2:15 p.m., with the agency’s DPCS, the DPCS stated Patient 12 had no recent hospitalization, no falls, no wound care, and have no rehabilitation services performed. DPCS stated that based on the patient assessment and visit notes, her goals have been met, and should have been discharged. During a review of the agency’s undated policy and procedure titled, "Discharge Criteria and Process", indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician (or other authorized licensed independent practitioner) and the organization agree that the goals of home care have been attained or are no longer attainable.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutics to a patient at home) failed to maintain an accurate, current medication profile (a comprehensive record of all the medications that a patient is currently taking) for two of seven patients (Patients 1 and Patient 5). This deficient practice has the potential to result in putting the patient at risk for medication errors and adverse drug reactions (a harmful, unintended result caused by taking medication). During a review on 8/17/2024 of Patient 5's document titled "Initial Assessment Form:" by the Mobile medical Group dated 7/10/2024, indicated that Patient 5 is a 62-year-old, female, alert, oriented x 4 (to name , place , person and time) who lives with family primary language is Armenian but also fluent in English. Patient with comorbidities which put her at risk for hospitalization and complication. Patient with significant medical problems including Asthma (a chronic lung disease that affects the airways in the lungs, making it difficult to breathe), Nicotine Dependence (an addiction to tobacco products caused by the drug nicotine), Back Pain, Vitamin D Deficiency, Generalized Anxiety Disorder (a mental health condition that causes people to feel excessive worry and fear about everyday things for months or years), Leg Edema (swollen legs), Iron Deficiency Anemia , Folic Acid Deficiency, Muscle Weakness and Overweight. She reports SOB on exertion, has noted Asthma. Current Smoker- Difficult for her to quit. Has inhalers with fair relief. Unable to tolerate strenuous activities. She takes Spironolactone - denies any hypertension or history of heart failure. Unsure why she uses it, but she c/o on and off lower leg swelling. Has chronic neck and back pain. Pain worse with movements or activities which makes it difficult to perform ADLs. Patient requires assistance with some ADLs. Due to patient's comorbidities, weakness and pain, it is difficult and unsafe for the patient to leave home for a clinic visit. Thus, will benefit from home health services. During a review on 8/17/2024 at 2:00 p.m., of the “Orders for Discipline and Treatments” indicated skilled nurse (SN) visit frequency of once a week for nine weeks. SN admitted the patient for comprehensive skilled nursing assessment, observation and evaluation of all bodily systems. SN to assess vital signs, pain level and ability to perform activities of daily living (ADLs) tasks. SN to evaluate therapeutic response to current /new medications and compliance to medication/diet regimen, home safety issues and psychosocial adjustment. During a joint home visit at Patient 4’s residence with Registered Nurse 1 (RN1) on 8/16/2024 at 11:15 a.m., Patient 5 was found sitting in the living room. Patient 5 is alert and oriented to name, place and person and uses a cane for walking. RN 1 proceeded with her assessment. During a review on 8/16/2024 at 11:30 a.m., of Patient 5's current medication profile at home indicated that two medications were not not listed. Omeprazole 40 milligrams 1 tablet daily for hyperacidity and Silver Sulfadiazine 1% cream apply to affected area three times daily as needed. During a concurrent interview at the same date and time with RN , RN 1 stated that she updates the medication profile every home visit. RN 1 also stated that she calls the home health agency office for any updates in the medication orders. During an interview with the Director of Nursing (DON) on 8/17/2024 at 3:00 p.m., DON agreed that any forms , physician's orders nurses notes should be filed inside the patient's charts upon receipt. During an interview with the Administrator (Admin) on 8/17/2024 at 3:10 p.m., stated that the office personnel receives all the calls from doctors, nurses notes and updates , prints the papers and is supposed to file them in the patient's charts. Admin stated it piled up and he needs to sort them and file in the patient's charts. During a review of the undated agency's policy titled "Medication Profile/Reconciliation" indicated Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization w II obtain and document a complete list of the patient's current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient file under the organization's care will be made to those on the list. The admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use for each medication ordered. A review of Patient 1's Patient Information indicated, a start of care (SOC) date of 7/2/2024, with diagnosis that included type two diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Patient 9's starting from 5/30/2024 to 7/28/2024, for comprehensive skilled nursing assessment, During a review of Patient 1's Home Health Certification and Plan of Care for the certification period from 7/2/2024 to 8/30/2024, included an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks, for skilled nurse (SN) to visit for recertification evaluation, assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication, and compliance. SN was also to instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). There was a physician's order included in the POC to administer Brimonidine 0.2 percent ophthalmic solution, to instill one drop into both eyes twice daily and Latanoprost 0.005 percent ophthalmic solution, to instill one drop into both eyes daily. On 8/16/2024, at 12 p.m., a home visit was conducted at Patient 1's residence with license vocational nurse (LVN 2). Patient 1 was observed ambulating with steady gait without using an assistive device. During a review of Patient 1's medications indicated a bottle of Brimonidine 0.2 percent ophthalmic solution with an expiration date of May 2024 and a bottle of Latanoprost 0.005 percent ophthalmic solution with an expiration date of 2/2024. At 12:30 p.m., during an interview with Patient 1, she stated the visiting nurse would just ask if there were any new medications but does not check the actual medication bottles during the visits. During an interview with the DPCS on 8/18/2024, at 11 a.m., the DPCS stated the visiting nurse should always check the actual medication bottles at every visits.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed for the skilled nurse (SN) to ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial [used to describe the influences of social factors on an individual's mental health and behavior], and cognitive [mental process involved in knowing, learning, and understanding things] status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) of the patient's need for blood sugar check was verified and updated, for one of 7 sampled patients (Patient 4). This deficient practice had the potential for Patient 4's care needs to check and monitor blood sugar not be identified and provided timely interventions. Findings: During a review of Patient 4’s “Home Health Certification And Plan of Care” for the certification period of 7/17/2024 to 9/14/2024, indicated Patient 4's start of care (SOC) was 3/19/2024 with the primary diagnosis of neuropathy (are nervous system disorders that interfere with normal nerve function, whether motor or sensory) and prediabetes (a serious health condition that occurs when your blood sugar levels are higher than normal but not high enough to be diagnosed as type 2 diabetes). During a review of Patient 4's “Orders for Discipline and Treatments” indicated a skilled nurse (SN) visit frequency of three to four times as needed. SN to continue to perform every visit: diabetic foot exam upon every visit. SN to record blood sugar test results checked by patient/caregiver during the visits and report any significant changes to medical doctor (MD). Patient 4's “Orders for Discipline and Treatments” indicated for SN to continue to report to primary medical doctor (PMD) signs and symptoms of hypoglycemia (low blood sugar level) hyperglycemia (high blood sugar level). During a review of Patient 4's “Goal/Rehabilitation Potential/Discharge Plans” indicated that in five to six weeks, patient/caregiver will verbalize understanding of diabetes management (leading a healthy lifestyle, taking medicines, and managing your blood glucose [sugar] level) as evidenced by blood sugar maintained within the range of 80-200 milligrams per deciliter (mg/dl- unit of measurement). Patient 4's “Goal/Rehabilitation Potential/Discharge Plans” indicated that within eight to nine weeks, Patient 4 and caregiver will be free from signs and symptoms of hypo/hyperglycemia throughout the episode. During a joint home visit on 8/16/2024 at 10:00 a.m., at Patient 4’s residence, with Registered Nurse 1 (RN1), Patient 4 was observed sitting outside the home. Patient 4 was alert and oriented to name, place and person and used cane to walked. RN 1 proceeded with her assessment. During an observation and an interview on 8/16/2024 at 10:15 a.m., with RN 1 and Patient 4, during RN 1 visit, RN 1 did not ask Patient 4 about the blood sugar level. RN 1 stated that Patient 4 could check his own blood sugar. Patient 4 stated “I have not checked my blood sugar a long time ago and I stopped checking it. I am not diabetic.” Patient 4 stated he has his own glucometer (a device for measuring the concentration of glucose (sugar) in the blood). Patient 4 stated he has not used it for some time and did not know where it is. During an interview on 8/17/2024 at 3 p.m., with the Director of Nursing (DON), the DON stated that the admitting nurses should conducted their reassessments and updated the plan of care for the patient’s needs. A review of the agency’s undated policy titled “Initial and Comprehensive Assessment” indicated the assessment will be patient-specific and comprehensive to include the patient's need for home care, rehabilitative care, social, and discharge planning needs. The assessment will also include the exact use of the current versions of the Outcomes and Assessment Information Set (OASIS- a standardized assessment tool used in Medicare home health care to improve patient outcomes). This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter. During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient's progress towards goals and other relevant information will be documented in the patient's clinical record.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing care to patients in the comfort of their home) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities] program) for Clinical Records was met as follows: The home health agency (HHA) failed to ensure the clinical record of four of 12 sampled patients (Patient 9, Patient 10, Patient 11 and Patient 12) included routine visit clinical notes that reflected the patient's current health status. As a result, Patient 9, Patient 10, Patient 11, and Patient 12 did not have completed clinical records that could potentially affect the patients’ care and services and could lead to potential hospitalization or death. (Refer to G1012). The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with the Clinical Records to ensure quality of care was provided to the patients (Patient 9, Patient 10, Patient 11, and Patient 12) who were assessed to receive home care and services.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the patient clinical records of four of 12 sampled patients (Patient 9, Patient 10, Patient 11, and Patient 12) included routine visit clinical notes that reflected the patient's current health status. As a result, Patient 9, Patient 10, Patient 11, and Patient 12 did not have completed clinical records that could potentially affect the patients’ care and services that could lead to potential hospitalization or death. On 8/17/2024, at 5:08 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Director of Patient Care Services (DPCS) and Office Manager (OM) related to the home health agency (HHA) failure to ensure the patient clinical records of four sampled patients (Patient 9, Patient 10, Patient 11, and Patient 12) included routine visit clinical notes that reflected the patient's current health status. The non-compliance resulted in incomplete clinical records that does not reflect patients' current condition and needs which likely to cause unidentified needs, serious injury, harm, impairment, or death to a patient. On 8/17/2024, at 5:30 p.m., the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team completed the survey tasks and conducted an exit conference, with the DPCS, with the IJ situation not removed. Findings: During an interview on 8/17/2024, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the HHA had four active patients (Patient 9, Patient 10, Patient 11, and Patient 12) with continuous re-certification periods for HHA services. During an interview with the DPCS, on 8/17/2024, at 12:30 p.m., a request was made from the DPCS to provide a copy of the Patient 9’s, Patient 10’s, Patient 11’s and Patient 12's routine visit clinical notes. The DPCS stated she could not find the visit notes in their electronic charting (E-chart). The DPCS stated the patients’ clinical records should be available and accessible especially to the nursing clinical staff to know the current condition and status of the patients under their care to prevent any potential harm to the patient. The DPCS stated she was not able to provide any pertinent clinical records to the survey team that includes the patient’s initial comprehensive assessment, plan of care, medication profile sheet and nursing visit notes. a. During a review of Patient 9's Patient Information sheet, the Patient Information sheet indicated a Start of Care (SOC) date of 5/30/2024, with a diagnosis of spondylosis (age related wear and tear of the spinal disk). During a review of Patient 9's Home Health Certification and Plan of Care for the re-certification period starting from 7/28/2024 to 8/16/2024, the Home Health Certification and Plan of Care included an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks to assess vital signs (clinical measurements, specifically pulse rate, temperature, respiration [the action of breathing] rate, and blood pressure [a measure of how forcefully your blood goes through your blood vessels], that indicate the state of a patient's essential body functions), pain level, to evaluate therapeutic response and compliance to current and new medications and diet regimen. During a review of Patient 9's clinical record (in general), the clinical record indicated there were no nursing visit notes from the re-certification period dates 7/28/2024 to 8/16/2024. b. During a review of Patient 10's Patient Information sheet, the Patient Information sheet indicated a SOC date of 2/1/2024 with a diagnosis of idiopathic neuropathy (a condition that affects the peripheral nervous system and causes nerve damages for which there is no known cause). During a review of Patient 10's Home Health Certification and Plan of Care for the re-certification period starting from 7/29/2024 to 10/28/2024, the Home Health Certification and Plan of Care included an order for the SN frequency of visits of once a week for nine weeks to assess vital signs, pain level, to evaluate therapeutic response and compliance to current/new medications and diet regimen. During a review of Patient 10's clinical record (in general), the clinical record indicated there were no nursing visit notes from the re-certification period dates 7/29/2024 to 8/15/2024. c. During a review of Patient 11's Patient Information sheet, the Patient Information sheet indicated a SOC date of 1/6/2024 with a diagnosis of type II diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels). During a review of Patient 11's Home Health Certification and Plan of Care for the re-certification period starting from 7/4/2024 to 9/1/2024, the Home Health Certification and Plan of Care included an order for the SN frequency of visits of once a week for nine weeks to assess vital signs, pain level, to evaluate therapeutic response and compliance to current/new medications and diet regimen. During a review of Patient 11's clinical record (in general), the clinical record indicated there were no nursing visit notes found from re-certification dates of 5/5/2024 to 7/3/2024, and 7/4/2024 to 8/15/2024. d. During a review of Patient 12's Patient Information sheet, the Patient Information sheet indicated a SOC date of 5/25/2024 with a diagnosis of idiopathic neuropathy. During a review of Patient 12's Home Health Certification and Plan of Care for the re-certification period starting from 7/4/2024 to 9/1/2024, the Home Health Certification and Plan of Care included an order for the SN frequency of visits of once a week for nine weeks to assess vital signs, pain level, to evaluate therapeutic response and compliance to current/new medications and diet regimen. During a review of Patient 12's clinical record (in general), the clinical record indicated there were no nursing visit notes found from re-certification period dates from 5/25/2024 to 7/23/2024, and 7/4/2024 to 8/15/2024. During a review of the agency’s undated policy and procedure (P&P) titled, “Contents of the Clinical Records,” the P&P indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel.