Every finding on record at Legacy Home Health, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted May 19, 2025, through May 22, 2025. Census: 57 Unduplicated Admissions: 154 Home Visits with Record Review: 3 Record Reviews without Home Visits: 4 Sample Size: 7 All Conditions of Participation for Emergency Preparedness were met.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure their Emergency Preparedness Plan was being implemented when three of 21 staff members were not knowledgeable about the facility’s designated alternate meeting location in case of emergencies. This failure has the potential for delay in the overall facility communication and coordination of services for 57 patients who received care from the facility. Findings: During an interview on May 20, 2025, at 11:35 AM, with Certified Home Health Aide (CHHA), in Patient 1’s home, CHAA stated she was aware the office parking lot was the primary emergency meeting location, but she was not aware of alternate emergency meeting location. During an interview on May 20, 2025, at 1:30 PM, with Licensed Vocational Nurse (LVN), in Patient 2’s home, LVN stated she did not know where the facility’s alternate meeting location was. LVN further stated she would probably go to Administrator's (ADMIN) house. During an interview on May 20, 2025, at 4:45 PM, with Speech Therapist (ST), in Patient 3’s home, ST stated she did not know the facility’s alternate meeting location in case of emergencies. During an interview on May 21, 2025, at 4:15 PM, with the ADMIN, the ADMIN stated facility staff should know where the facility’s designated alternate meeting location was in case of emergencies. The ADMIN further stated that, “All staff should have been educated and in serviced on emergency preparedness, they should know the alternate meeting location was the home address of Clinical Nurse Manager (CNM)”. During a concurrent interview record review on May 21, 2025, at 4:25 PM, with the ADMIN, the ADMIN reviewed the facility’s undated policy and procedure titled (P&P), “Emergency Preparedness Plan”, which indicated, “PROCEDURES 1. All staff members will be orientated to the emergency preparedness plan and their associated responsibilities during orientation. Continuity of Operations-Alternate Office Location: In the event of damage, inaccessibility, or other circumstances that prevent regular use of the primary office, operations will continue from designated alternate location”. The ADMIN stated the agency staff did not follow the policy.

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted May 19, 2025, through May 22, 2025. Census: 57 Unduplicated Admissions: 154 Home Visits with Record Review: 3 Record Reviews without Home Visits: 4 Sample Size: 7 All Conditions of Participation was met.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure personal health information were kept confidential when Certified Home Health Aide (CHHA) received and sent Patient 1’s clinical records using her personal cell phone. This failure resulted in Patient 1’s personal health information being put at risk by not keeping health records confidential, and using personal equipment not being monitored and secured by the agency. Findings: During a review of Patient 1’s face sheet (contains demographic and medical information), it indicated Patient 1 had a start of care date of August 11, 2024, with a recertification period (time frame during which a patient receives home health care services, generally lasting 60 days) of February 7, 2025, through April 7, 2025. Patient 1 had diagnoses of dementia (a group of symptoms affecting memory, thinking and social abilities), hypertension (high blood pressure) and hyperlipidemia (high levels of fat in the blood). During a home visit observation on May 20, 2025, at 11:35 AM, with CHHA, CHHA was reviewing Patient 1”s “Aide Care Plan” (detailed document that outlines the specific care and services a home health aide will provide to a client in their home) on her personal cell phone. During a subsequent interview with CHHA, on May 20, 2025, at 11:45 AM, CHHA confirmed she used her personal cell phone to send and receive Patient 1’s medical information to the facility’s main office. During an interview on May 21, 2025, at 3:50 PM, with the Administrator (ADMIN), the ADMIN stated the facility staff were only supposed to send patient information using the facility’s electronic application called [name of the software]. The ADMIN further stated facility staff should not be using their personal phones to send patient’s information to the facility’s cellular (cell) via text messages. During a concurrent interview and record review on May 21, 2025, at 4:10 PM, with the ADMIN, the ADMIN reviewed the facility’s undated P&P, titled, “Transmission Security”, which indicated, “To ensure the confidentiality, integrity and availability of electronic protected health care information (ePHI, technical security measures to guard against unauthorized access. …[name of facility] will take appropriate steps to implement security measures to protect the integrity of ePHI while it is being transmitted over electronic communications networks…Procedure… [name of facility] will use integrity controls to ensure that the value and state of its ePHI is maintained during transmission and that ePHI is protected against unauthorized alteration or destruction during transmission over electronic communication networks…3. Protected health information stored, whether intentionally or not, in a photocopier, facsimile and other devices is subject to the HIPAA Privacy and Security Rules…Encryption 1. When deemed necessary, encryption will be used to protect ePHI during transmission over electronic communications networks…”. The ADMIN stated the policy was not followed by the staff. During a review of the facility’s policy and procedure (P&P) titled, “Health Information Management Policy and Procedure Manual”, dated August 1, 2020, it indicated, “PUPOSE- To ensure the security and privacy of all patent’s medical records. [name of facility], will take appropriate steps to implement security measures to protect the integrity of ePHI [any individual identifiable health information held or transmitted by a covered entity or its business associate] while it is being transmitted over electronic communications”.

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 facility failed to ensure the performance improvement project (PIP- concentrated effort on a particular problem in one area of the facility or facility wide; involves gathering information systematically to clarify issues or problems and intervening for improvements) of their Quality Assessment and Performance Improvement (QAPI) Program was in progress or in development as per their policy and procedure. This failure resulted in the facility to have missed opportunities for the evaluation and improvement in care services in areas that the facility identifies as needing attention, which had the potential to affect 57 patients. Findings: During a concurrent interview and record review on May 22, 2025, at 11:30 AM, with the Clinical Nurse Manager (CNM), the CNM reviewed the QAPI meeting minutes from the first quarter of 2024 through fourth quarter of 2024. The CNM stated the facility did not have a performance improvement project in progress or in development. The CNM further stated the facility only had quality metrics which they collect data for and review on a quarterly basis. During further interview, the CNM stated the quality metrics discussed in QAPI every quarter were outcome of general chart audits, infection control reports, hand hygiene compliance reports, complaint and grievance reviews, medication error and hospitalizations. The CNM further stated the facility did not have any currently identified issues in the quality metrics. The CNM further stated the facility did not have any projects they were working on from the first quarter of 2024 to present During a concurrent interview and record review on May 22, 2025, at 1:45 PM, with the CNM, the CNM reviewed the facility’s policy and procedure (P&P) tiled, “Organizational Quality Assessment and Performance Improvement (QAPI) Program”, dated January 1, 2021, which indicated, “PURPOSE-The HHA develops, implements, evaluates and maintains an effective, ongoing, HHA-wide, data driven QAPI program. The HHA governing body must ensure that the program reflects the complexity of its organization and services. GOALS: The primary goals of the organizational QAPI program shall be to continually and systematically plan, design, measure, assess and improve performance of organization wide key functions and processes relative to patient care, treatment and services”. The CNM stated the facility did not follow the P&P.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow infection control guidelines when expired medical supplies were found on the medical supply room and were available for use. This failure had the potential to put the facility’s 57 patients at an increased risk of infection (the invasion and growth of germs like bacteria, viruses or fungi in the body, which can cause illness or damage to tissues) and other complications of infectious microorganism. Findings: During a facility tour on May 19, 2025, at 11:30 AM, in the conference room/medical supply room, with Registered Nurse/Office Staff (RN), the following medical supplies were found to be expired and were available for use: 1. Six pieces of [Brand Name] Urinary leg bag (small, urine drainage bag worn on the thigh or lower leg) with an expiration date of October 31, 2024. 2. Six pieces of [Brand Name] Intermittent Catheter (thin, flexible tube inserted into the bladder through the urethra to drain urine) Uncoated 16 Fr (“Fr stands for French,” and its unit of measurement for catheter sizes) with an expiration date of September 30, 2023. 3. Five pieces of [Brand Name] 16 Fr Foley catheter with an expiration date of September 30, 2023. 4. Two pieces of [Brand Name] Silicone Coated Latex Foley Catheter 20 Fr with an expiration date of January 10, 2019. 5. One piece of [Brand Name] Foley Insertion Tray with an expiration date of September 30, 2024. 6. Two pieces of StatLock (catheter stabilization device) with an expiration date of April 28, 2024. 7. Two pieces Nasal Oxygen Cannula with an expiration date of January 13, 2024. 8. Two pieces of IodoForm Packing Strip with an expiration date of January 1, 2024. 9. One box of (50 wipes) SKIN-PREP Protective Wipes with an expiration date of December 12, 2023. The RN verified that all the medical supplies were expired and should have been discarded. During a concurrent interview and record review on May 19, 2025, at 12:15 PM, with the Administrator (ADMIN), the ADMIN reviewed the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control”, dated November 1, 2021, which indicated, “POLICY [name of facility]. Will implement measures to prevent and control the spread of infection. Prevention strategies will focus on educating the staff providing home care, the clients receiving services, and their families. PROCEDURES-1. An infection is controlled through prevention measures that discourage the spread of infection. 2. Prevention strategies for employees providing client care services are: a. Check all supplies for expiration dates”. The ADMIN stated the medical supplies should have been checked regularly and expired items should have been discarded. The ADMIN further stated the facility did not follow the infection prevention and control policy.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure criminal background check was performed prior to hire or prior to working with patients for one of six sampled employee (Speech Therapist (ST)). This failure resulted in the agency to allow staff to have access to patients without first ensuring their (staff) background was clear of criminal history related to abuse, neglect, or mistreatment, and had the potential to place 57 patients at risk. Findings: During an observation on May 20, 2025, at 4:25 PM, at Patient 3’s home, ST arrived and provided in-home speech therapy (a healthcare profession that focuses on the assessment, diagnoses, and treatment of disorders related to speech, language, communication, and swallowing) services. During a record review of ST’s employee file on May 21, 2025, at 11:00AM, there was documented evidence to indicate a criminal background check was performed for ST prior to hire. During an interview on May 21, 2025, at 11:45 AM, with the Administrator (ADMIN), the ADMIN stated ST was a contracted staff member who worked for the agency through a contracted registry called [name of the contracted staffing registry] which provided staff to perform speech therapy. The ADMIN further stated the agency did not have documentation of a background check on file for ST. During an interview on May 21, 2025, at 3:45 PM, with the ADMIN, the ADMIN stated the importance of a background check was to ensure staff didn’t have any criminal history prior to working with patients and to ensure they were able to legally work in the United States. During a concurrent interview and record review on May 21, 2025, at 3:55 PM, with ADMIN, the admin reviewed the facility’s policy and procedure (P&P) titled, “CATEGORIES/QUALIFICATIONS OF PERSONNEL”, dated November 2023, which indicated, “POLICY 3. The organization will employ or contract only those individuals who have valid credentials as stipulated by the state and federal requirements. 4. Personnel qualifications include appropriate professional licensure, certification, and absence of a criminal background for those positions designated by law and regulation”. The ADMIN stated the agency did not follow the policy and procedure.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure patients clinical records were stored in locked, waterproof file cabinets in a designated clinical records room in accordance with the facility’s policies and procedure. This failure had potential for 210 patient’s clinical record information to be lost or be at risk of unauthorized use. Findings: During a concurrent observation and interview on May 19, 2025, at 11:40 AM, with the Registered Nurse (RN) and Office Staff (OS), in the medical record room, there were 210 patient’s medical records stored inside 10 cardboard boxes in the room. The RN and OS stated the agency kept the discharged patient’s medical records in the cardboard boxes to review the files. The RN stated, “While we review the patient’s medical files, the files are kept in cardboard boxes in the medical records room, not in metal cabinets”. During a concurrent interview and record review on May 19, 2025, at 4:10 PM, with Administrator (Admin) and Clinical Nurse Manager (CNM), the ADMIN and CNM reviewed policy and procedure (P&P) titled “SAFEGUARDING/RETRIEVAL OF CLINICAL RECORDS,’ dated November 2023, which indicated, “PROCEDURE: 1. All physical patient clinical/service records will be maintained in locked, waterproof file cabinets in a record room: C. The clinical/service record room will not be left unattended during working hours. D. If the room is left unattended during business hours, the door will be locked. E. Only authorized personnel will have access”. The Admin and CNM stated the agency did not follow the procedure.

. The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted April 25, 2022 through April 28, 2022. Representing the Department of Public Health: Surveyors: 33786 41459 Census: 41 Unduplicated Admissions: 121 Home Visits with Record Review: 3 Record Reviews without Home Visits: 4 Sample Size: 7

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted April 25, 2022 through April 28, 2022. Representing the Department of Public Health: Surveyors: 33786 41459 Census: 41 Unduplicated Admissions: 121 Home Visits with Record Review: 3 Record Reviews without Home Visits: 4 Sample Size: 7

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based observation, interview, and record review, The home health agency (HHA) failed to provide the names, addresses, and telephone numbers of federally and state-funded entities for one of 7 sampled Patients (Patient 5). This failure resulted in Patient 5 not having the names, addresses, and telephone numbers of federally and state-funded entities available for use as a resource. Findings: During a review of the Patient 5's face sheet (a document which contains basic information about the client) had a start of care date of October 21, 2021, which a certification period of February 18, 2022 through April 18, 2022. Patient 5 had diagnoses which included cirrhosis of the liver, Gastro-esophageal reflux disease (Heartburn), and anemia (loss iron in the blood). During a home visit on April 27, 2022, at 10:15 AM, with Patient 5, she was observed laying in bed. She is alert and verbally responsive. The HHA's admission packet was on top of the table. During a review of Patient 5's HHA's admission packet, the admission packet did not contain the names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. During an interview with Patient 5 on April 27, 2022, at 10:30 AM, Patient 5 stated, "I do not know of any telephone numbers." During an interview with the DNS on April 28, 2022, at 9:45 AM, DNS confirmed Patient 5's HHA's admission packet did not have a list of names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The DNS stated, "I did not know the clients needed a list of names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. We have not been doing that. I will fix it right away." A request was made for the agency's policy and procedure concerning the names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The agency did not provide a policy and procedure.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide information on how to access auxiliary aids and language services for one of 7 sampled Patients (Patient 5). This failure resulted in Patient 5 not to be informed on how to access auxiliary aids and language services as a resource. Finding: During a review of the Patient 5's face sheet (a document which contains basic information about the client) had a start of care date of October 21, 2021, which a certification period of February 18, 2022 through April 18, 2022. Patient 5 had diagnoses which included cirrhosis of the liver, Gastro-esophageal reflux disease (Heartburn), and anemia (loss iron in the blood). During a home visit on April 27, 2022, at 10:25 AM, with Patient 5, she was observed laying in bed. She is alert, and verbally responsive. The HHA's admission packet was on top of the table. During a review of Patient 5's admission packet, the admission packet did not contain information on how to access auxiliary aids and languages. During an interview with Patient 5 on April 27, 2022, at 10:30 AM, Patient 5 stated, "I do not know of any information on how to access auxiliary aids and languages." During an interview with the Director Of Nursing Services, (DNS) on April 28, 2022, at 9:45 AM, DNS confirmed Patient 5 did not have information on how to access auxiliary aids and languages. The DNS stated, "We have not been doing that. I will fix it right away." A request was made for the agency's policy and procedure concerning the right to access auxiliary aids and languages services. The agency did not provide a policy and procedure.

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 home health agency (HHA) failed to document the existence and the resolution of one complaint/grievance for the month of September and one complaint/grievance for the month of October 2021. This failure had the potential for the HHA’s Patients’ complaints/grievance to go untracked and unresolved. Findings: During a review of the HHA's performance tracking complaints/grievances log book on April 27, 2022, at 3:45 PM with the Director of Nursing Services (DNS), the HHA's performance tracking complaints/grievances log book documented one complaint/grievance for the months of September 2021 and one complaint/grievance for the month of October 2021. Further review of the HHA's performance tracking complaints/grievances log book for the months of September and October 2021, there was no documented evidences who made the complaint/grievance, the description of the complaint/grievance, and the resolution of the complaint/grievance. During an interview with the DNS on April 28, 2022, at 4:20 PM, the DNS confirmed there was no documented evidence in the performance tracking complaint/grievance log book who made the complaint/grievance, the description and the resolution of the complaint/grievance. The DNS stated, "It was done but it is misplaced. I do not have it. It should in the log book." During a review of the HHA's policy and procedure, titled, " Plexus Healthcare: Grievance Procedures,” undated, indicated, “Any patient, patient representative, prospective patient, or Plexus staff member who has reason to believe that he or she has been mistreated, denied services, or discriminated against in any aspect of services or employment may file a grievance.” Further review of the HHA’s policy and procedure titled, “Plexus Healthcare: Grievance Procedures,” undated, indicated, “4. Shall issue a written decision determining whether the grievance is valid no later than 15 days after filing.”

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 observation, interview, and record review, the agency failed to follow infection control guidelines risking cross contamination in one (1) of seven (7) sampled patients (Patient 7) when a nursing supply bag was placed on Patient 7’s living room floor without a barrier. This failure had the potential for patients to suffer inferior care practices risking transmission of infectious agents through cross contamination. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care of March 10, 2022, with a certification date of March 10, 2022 to May 8, 2022. Patient 7 had diagnoses of hypertensive chronic kidney disease with stage 5 chronic kidney disease (kidneys are very close to not working of have stopped working), end stage renal disease (kidneys have ceased functioning on a permanent basis leading to dialysis), dementia (impairment of at least two brain functions, such as memory loss and judgement). During a home visit on April 27, 2021, at 1:00 PM, Patient 7 was observed having oxygen administered at 2 liters per minute (lpm – every liter per minute of oxygen increases the percentage of oxygen provided to the patient by about 3-4%) via nasal cannula (a device used to deliver supplemental oxygen or increased air flow to a patient or person in need of respiratory help). Patient 7 did not have an order for the use of oxygen, which is considered drug therapy… During an interview at a home visit with the Licensed Vocational Nurse (LVN – provides patients with quality care and comfort measures under the supervision of registered nurses), on April 27, 2021, at 1:20 PM, he verified that Patient 7 was wearing oxygen at 2 lpm via nasal cannula. During an interview on April 28, 2022, at 10:00 AM, with the DPCS, he confirmed that there was no physician order for Patient 7 to have oxygen at 2 lpm via nasal cannula in the home. During a record review of the policy and procedure titled, “Physician Orders,” dated August 1, 2020, indicated the following: “Policy: 1. Drugs and treatments are administered by agency staff only as ordered by the attending physician, 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/her scope of practice within 30 working days. …8. Orders for therapy services shall include the specific procedures to be used and the frequency and duration. Orders may only be within that scope of practice allowed by the licensure of the discipline involved. 9. All orders shall be reviewed by the attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice at least every 60 days. 10. Medications and treatment shall be administered as prescribed and shall be recorded in the patient’s health record, as administered. Purpose: 1. To document orders for client care that the nurse/therapist responsible for managing or supervising client care receives directly from the physician. 2. To provide documentation that orders taken by designated staff are communicated to the Supervising Nurse or Therapist. Procedures: All orders for medications must contain the name of the drug, dosage, route of administration, and directions. …6. The nurse or therapist shall document implementation of order changes and instructions given to clients. 7. A copy of the order must be placed in the chart until the order is authenticated. 8. All signed physician orders shall be maintained in the clinical record.”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to follow infection control guidelines risking cross contamination in one (1) of seven (7) sampled patients (Patient 7) when a nursing supply bag was placed on Patient 7’s living room floor without a barrier. This failure had the potential for patients to suffer inferior care practices risking transmission of infectious agents through cross contamination. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care of March 10, 2022, with a certification date of March 10, 2022 to May 8, 2022. Patient 7 had diagnoses of Hypertensive chronic kidney disease with stage 5 chronic kidney disease (kidneys are very close to not working of have stopped working), End stage renal disease (kidneys have ceased functioning on a permanent basis leading to dialysis), dementia (impairment of at least two brain functions, such as memory loss and judgement). During a home visit on April 26, 2022, at 1:00 PM, an Licensed Vocational Nurse – LVN (someone who works in a setting caring for disabled, sick, or otherwise injured patients), an observation was made when the LVN placed his nursing bag on Patient 7’s living room floor without a barrier ( a device used to limit potentially infectious contact between health care providers and patients) to separate the nursing supply bag from the living room floor risking cross contamination of infectious agents. During an interview on April 26, 2022 at 1:00 PM with LVN 2 was asked about the policy and procedure in regards to infection control and placing items down in a patients home. LVN 2 agreed there was no barrier between the nursing bag and the living room floor. During an interview with the Registered Nurse/Director of Patient Care Services] on April 26, 2022, at 4:00 PM, she stated, for infection control a barrier should be placed under the nursing bag at all times during a home visit. During a record review of the policy and procedure, titled, “Infection Prevention and Control”, dated August 1, 2020, indicated the following: “Policy: Plexus Healthcare, Inc. will implement measures to prevent and control the spread of infection. Prevention strategies will focus on educating the staff providing home care, the clients receiving services, and their families. Purpose: The primary emphasis is to prevent the transmission of infection from employee to client, client to employee and employee to employee. Procedures: 1. An infection is controlled through prevention measures that discourage the spread of infection. The following measures will be addressed: g. Identification of infectious activities and incidences, 2. Prevention strategies for employees providing client care services are: b. Follow policies and procedures established for the cleaning and disinfection of equipment and supplies, f. Follow established policies and procedures for infection control on handwashing, aseptic technique, and equipment cleaning, 3. Home care clients will be instructed , as needed, depending on the client’s infectious status or risk thereof, in the following infection prevention strategies: b. Maintaining clean equipment and supplies, c. Use of protective equipment and precautions to be taken to protect client and family members”. During a record review of at policy and procedure, titled, “Nursing Bag,” undated, indicated the following: "Purpose: To carry adequate supplies for home care clients, to maintain supplies in clean environment. Guidelines: When in a client’s home, place the bag on a clean and dry surface. If there is no suitable place in the home, take only those items into the home that are needed for the visit. “

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to follow their policy and procedure for tracking and documenting COVID-19 ( a respiratory disease which causes difficulty in breathing) vaccination status of staff who received COVID 19 boosters. This failure resulted in the HHA not following their policy and procedure for tracking and documenting the COVID 19 vaccination status of staff who received COVID 19 boosters. Findings: During a review of the HHA document titled, “[name of the agency], Inc. Vaccinated Individuals Tracking form,” with the Director of Nurses Service (DNS) on April 28, 2022, at 9:15 AM, indicated 24 staff received the COVID 19 vaccines. Further review of the HHA document titled, “[name of the agency], Inc. Vaccinated Individuals tracking Form” with the DNS, indicated there was no documented evidence the HHA tracked and documented staff who received COVID 19 boosters. During an interview with the DNS on April 28, 2022, at 9:30 AM, the DNS confirmed there was no tracking and documentation for staff who obtained COVID 19 boosters. The DNS stated, “I do not know if staff got the booster or not. I do not have that information. It should be tracked. It should be documented. I will find out and make phone calls.” During a review of the HHA's policy and procedure titled, “COVID 19 vaccination of personnel for Medicare and Medicaid Providers,” undated, indicated, “This organization will document and track the vaccination status of all employees including staff who are contracted, volunteers, or students. Documentation requirements include: booster vaccinations recommended by the Center for Disease Control and Prevention (CDC-The public health agency that protects people from health, safety, and security threats).” During a review of the HHA's policy and procedure titled, “COVID 19” dated August 1, 2020, indicated, “The agency is committed to the protection of patients and employees in the home care setting from the spread of infectious disease. The agency monitors the CDC website for information and resources..."

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure that the Home Health Aide was following the Home Health Aide Care Plan prepared by the Registered Nurse for one (1) of seven (7) sampled patients (Patient 2). This failure had the potential to cause the patient harm due to lack of care. During a review of Patient 2’s face sheet (a document that gives a summary of a patient’s information), undated, indicated a start of care date of July 31, 2021, a certification date of July 31, 2021 through September 28, 2021, and a certification date September 29, 2021 through November 27, 2021. Patient 2 had diagnoses that included hypertensive urgency (blood pressure is very high with minimal or no symptoms), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and adhesive capsulitis of leg (a painful condition that causes restriction of motion in the hip joint). During a record review of the Home Health Aide Care Plan for the certification period of July 31, 2021 through September 28, 2021, prepared by the Registered Nurse (RN- a nurse who has graduated from college’s nursing program and has passed a national licensing exam), indicated the nursing staff (home health aide – hands on custodial assistance provided in the home) caring for Patient 2 was given the assignment to perform the following tasks: take vital signs (temperature, pulse, blood pressure, respirations), shower, personal care, assist with dressing, hair care, shampoo, skin care, foot care, check pressure areas, assist with ambulation (walker), assist with mobility (shower), wash clothes, light housekeeping (bathroom), precautionary and other pertinent information (alone during the day, up as tolerated, vision deficit, glasses, hearing deficit, forgetful, diet: NAS (no added salt)heart healthy, low fat and low cholesterol, unsteady gait, high for fall risk, electric lift), Problems: personal care, maintaining safe environment, light housekeeping, due to right shoulder and knee pain patient having hard times get into shower needs assistance with activities of daily living, be exempt for avoidable accident or injury, no preventable accident injury or infection , satisfaction with personal care services. A record review of the Home Health Aide Visit Records for August 07, 2021, September 11, 2021, September 18, 2021, and September 25, 2021, indicated the Home Health Aide 2 was documenting bed baths or shower and not addressing the section titled, “Assist with Mobility.” The Home Health Aide did not follow the Home Health Aide Care Plan. A record review of the Home Health Aide Visit Record for August 14, 2021, indicated the Home Health Aide 2 documented “tub” under the section titled, “Assist with Mobility,” Equipment Care, and Electric Lift must wear seat belt at all times. The Home Health Aide did not follow the Home Health Aide Care Plan. A record review of the Home Health Aide Visit Record for August 21, 2021, indicated the Home Health Aide 2 was documenting “bed bath and tub” under the section titled, “Assist with Mobility”. The Home Health Aide did not follow the Home Health Aide Care Plan. A record review of the Home Health Aide Record for August 28, 2021, indicated the Home Health Aide 2 documented bed bath, tub under the section titled, “Assist with Mobility and electric lift. The Home Health Aide did not follow the Home Health Aide Care Plan. A record review of the Home Health Aide Visit Record for September 4, 2021, indicated the Home Health Aide 2 did not document for shower and did document tub under the section titled, “Assist with Mobility and Electric lift. The Home Health Aide did not follow the Home Health Aide Care Plain During an interview on April 27, 2022, at 3:30 PM, with the Director of Patient Care Services (DPCS – A supervisor position that combines administrative skills with nursing knowledge), she verified that the Home Health Aide Care Plan did not match the Home Health Aide Visit Record prepared by the Registered Nurse. During a record review of the policy and procedure titled, “Home Health Aide Plan of Care,” dated April 28, 2022, indicated the following: “Policy: Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide. Procedures: 1. The patient’s Case Manager or other appropriate skilled professional (physical therapist, occupational therapist, speech therapist) upon initialization of aide service will develop the writing home health aide plan of care, consistent with the comprehensive plan of care and physician (or authorized licensed independent practitioner) orders. 2. The home health aide plan of care will be individualized to the specific patient and will include at least: a. Type of services /procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance ambulation or exercise, b. fundamental limitations, c. patient’s mental status, d. activities permitted, e. nutritional requirements. 3. The Case Manager or the appropriate skilled professional will review the home health aide plan of care with the aide assigned to the case. The Case Manager, or other appropriate skilled professional, and assigned aide will sign the home health aide plan of care. 4. The Case Manager, or other appropriate skilled professional, will review changes to the home health aide plan of care with the assigned aide. The Case Manager or other appropriate skilled professional and aide will initial the plan to initiate this review. 5. The home health aide plan of care will be reviewed with patients to ensure understanding of the aide’s role in the home. 6. Home health aides are a member of the interdisciplinary team and shall report changes in the patient’s condition to a registered nurse or other appropriate skilled professional and shall complete appropriate documentation in compliance with organizational policies and procedures.” During a record review of the policy and procedure titled, “ Home Health Aide Services,” dated August 1, 2020, indicated the following: “Policy: Plexus Healthcare, Inc. provides home health aide services, as appropriate, based on the information from the comprehensive patient assessment at SOC (start of care) and Recert (recertification)/Follow-up, Purpose: To provide necessary home health aide services to patients, Procedures:… 4. Registered Nurse givers written instructions for patient care to the home health aide, as appropriate.”