Every finding on record at Lifelink Health Providers, Inc

The following reflects the findings of the California Department of Public Health during a Recertification survey and a complaint investigation conducted from 1/13/2026 to 1/16/2026. Complaint Number: 114093 Unduplicated admissions: 585 Census: 126 Sample Size: 13 Home Visits: 5 No deficiencies were written for complaint number: 114093.

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 provides skilled nursing and therapeutic services, such as physical, occupational or speech therapy, to individuals in their homes) failed to review and document medications and treatments the patients were receiving for three of 13 sampled patients (Patient 2, Patient 3 and Patient 7). These failures had the potential to place the patients at risk for drug-to-drug interaction, medication errors and medication adverse effects that could cause harm to patient's health. c. During a record review of Patient 7’s Patient Profile sheet indicated a start of care date of 11/10/2025, with diagnoses including presence of right artificial acute post procedure reverse total shoulder arthroplasty ( right shoulder replacement surgery with artificial device). During a concurrent interview and record review on 1/14/2026 at 10:55 am with physical therapy assistant 2 (PTA 2), at Patient 7’s residence, PTA 2 reviewed the medication Patient 7 was taking using record titled, Medication Profile, dated 11/10/2025. PTA 2 stated the following medications were at home, patient reported taking, but was not listed: -Tylenol 650mg, take 1 tablet by mouth every 4 hours daily as needed for arthritic pain -Losartan 50mg (a medication to lower elevated blood pressure) take 1 tablet by mouth daily -Loratadine 10mg (for allergies) 1 tablet daily -Raloxifene 60mg (used for postmenopausal women to prevent and treat osteoporosis and reduce the risk of invasive breast cancer) 1 tablet daily . -Rosuvastatin 20mg (medication for high cholesterol) 1 tablet daily -Wegovy 0.25mg (a medication for weight loss) 1 injection subcutaneous weekly. -ascorbic acid 1000mg tablet (vitamin C ) 2 tables twice daily. PTA 2 stated, “this was missed by the physical therapist and the nurse. Medication reconciliation needs to be done on every visit by physical therapists, occupational therapists and nurses. This is very important so we can keep track of all the current medications the patient has and communicate with the physician.” During an interview and record review on 1/15/2026 at 11:00 am., with DPCS, DPCS stated “medication reconciliation is supposed to be done every visit, this includes physical therapists as well nurses. They are supposed to do it on every visit. This was missed for these patients.” a. During a record review of Patient 2’s “Plan of Care” dated 11/28/2025 to 1/26/2026, indicated a start of care date of 6/1/2025 with a primary diagnosis of intrahepatic bile duct carcinoma (a rare, aggressive cancer that forms in the bile ducts located inside the liver). During a joint home visit, on 1/14/2026 at 12:35 p.m. with the Certified Occupational Therapy Assistant (COTA 1) at Patient 2’s residence. Patient 2 was observed ambulating and sitting down in the dining room. During a review of Patient 2’s current medication, on 1/14/2026 at 12:53 p.m. with COTA 1, the following medications were available in Patient 2’s residence but not listed in Patient 2’s medication profile provided by the HHA: Tylenol (used to treat pain reliever and a fever reducer )500 milligrams (mg – unit of measurement) – 1000 mg every 6 hoursIbuprofen (used to treat mild to moderate pain, and helps to relieve symptoms of arthritis) 800 mg – take one tablet three times daily as neededFamotidine (used to decrease stomach acid for treating ulcers) 20 mg – take one tablet twice dailyFurosemide (help treat fluid retention and swelling) 20 mg – take 1 tablet dailyb. During a record review of Patient 3’s “Plan of Care” dated 11/18/2025 to 1/16/2026, indicated a start of care date of 11/18/2025 with a diagnosis of fracture of lower end of femur (thigh bone). During a review of Patient 3’s current medication, on 1/14/2026 at 2:10 p.m. with the Director of Patient Care Services (DPCS), the following medications were not available in Patient 1’s residence but was listed in Patient 3’s medication profile provided by the HHA: Doxycycline Monohydrate (used to treat bacterial infections in many different parts of the body) 100 mg – 1 tablet twice dailyNitrofurantoin Monohydrate/Macrocrystals (used to treat urinary tract infections) 100 mg – 1 capsule twice dailyDuring a review of Patient 3’s current medication, on 1/14/2026 at 2:10 p.m. with the DPCS, the following medications were available in Patient 3’s residence but not listed in Patient 3’s medication profile provided by the HHA: Furosemide 20 mg – take 1 tablet dailyDocusate Sodium (used to relieve occasional constipation ) 100 mg – Take 1 capsule two times daily as neededThera Tears eye drops (used to relieve dry, irritated eyes by restoring moisture)Advance Eye Relief eye drops (used to provide temporary relief from dry, irritated, red, or burning eyes)During an interview on 1/16/2026 at 10:21 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that all disciples need to do medication reconciliation every visit. DPCS stated that it is important to do medication reconciliation every visit to make sure patients are taking the right medications and making sure agency is updated on new medications. During a record review of the agency’s policy and procedure, titled “Medication Profile” undated, the policy and procedure indicated, patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record and medication profile will be updated for each change to reflect medications, new, and/or discontinued medications.

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 Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services, such as physical, occupational or speech therapy, to individuals in their homes) failed to include information required in the plan of care (POC, a mandatory, written, and patient-specific document that outlines necessary medical, rehabilitative, and supportive services to treat an injury or illness at home) for three of 13 sampled patients (Patient 1, Patient 7 and Patient 9). This failure had the potential to result in patients not receiving the identified needs and services which could cause decline in health status and well-being. b. During a record review of Patient 7’s Patient Profile sheet indicated a start of care date of 11/10/2025, with diagnoses including presence of right artificial acute post procedure reverse total shoulder arthroplasty. During a record review of Patient 7’s POC dated 01/09/2026to 3/09/2026, recertified on 1/09/2026, the POC did not indicate any blood pressure or oxygen parameters to report to the physician. During an interview on 1/15/2026 at 11:15 am with DPCS, DPCS stated,” there are no physician reportable parameters for vital signs and oxygen in Patient 7’s plan of care. This was missed. It is important to have the physician reportable parameters for vital signs and oxygen because it guides the patient care for the clinicians, and they know what to report to the physician.” c. During a record review of Patient 9’s Patient Profile sheet indicated a start of care date of 8/21/2025, with diagnoses including pressure ulcer of left buttock ( break in the skin due to pressure injury), hypertensive heart disease (disease that caused high blood pressure), and chronic obstructive pulmonary artery ( a progressive group of lung conditions, primary emphysema and chronic bronchitis, that block airflow, making it hard to breath, cough and wheezing, and is mainly caused by long-term exposure to irritants like tobacco smoke . During a record review of Patient 9’s POC dated 12/19/2025 to 2/16/2026, recertified on 12/16/2025, the POC did not indicate any blood pressure or oxygen parameters to report to the physician. During an interview on 1/15/2026 at 11:20 am with DPCS, DPCS stated,” there are no physician reportable parameters for vital signs and oxygen in Patient 9’s plan of care. This was missed. It is important to have the physician reportable parameters for vital signs and oxygen because it guides the patient care for the clinicians, and they know what to report to the physician.” a. During a record review of Patient 1’s “Plan of Care” dated 11/25/2025 to 1/23/2026, indicated a start of care date of 9/26/2025 with a diagnosis of multi-system degeneration (progressive brain disorder that affects movement and balance and disrupts the function). The “Plan of Care” indicated that there was no documented vital sign parameter. During a concurrent interview and record review on 1/15/2026 at 11:20 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that the plan of care should have had vital sign parameters. DPCS stated that it is important to have vital sign parameters so that staff are aware what to report to the physician. During a record review of the agency’s policy and procedure, titled “Care Planning Process” undated, the policy and procedure indicated, the purpose of the policy and procedure is to provide clinical direction to the clinician providing direct patient care.

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 observation, interview, and record review the Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services, such as physical, occupational or speech therapy, to individuals in their homes) failed to provide written information regarding the plan of care (POC, a mandatory, written, and patient-specific document that outlines necessary medical, rehabilitative, and supportive services to treat an injury or illness at home) for two of 13 sample patients (Patient 1 and Patient 2). This failure had resulted in patients and their representatives not knowing their care team or their treatment course. a. During a record review of Patient 1’s POC dated 11/25/2025 to 1/23/2026, indicated a start of care date of 9/26/2025 with a diagnosis of multi-system degeneration (progressive brain disorder that affects movement and balance and disrupts the function). During a joint home visit on 1/14/2026 at 10:30 a.m. with the Physical Therapy Assistant (PTA) at Patient 1’s residence, Patient 1 was observed sitting down on a chair in the living room. There was no POC identified in Patient 1’s home. b. During a review of Patient 2’s POC dated 11/28/2025 to 1/26/2026, indicated a start of care date of 6/1/2025 with a primary diagnosis of intrahepatic bile duct carcinoma (a rare, aggressive cancer that forms in the bile ducts located inside the liver). During a joint home visit, on 1/14/2026 at 12:35 p.m. with the Certified Occupational Therapy Assistant 1 (COTA 1) at Patient 2’s residence, Patient 2 was observed ambulating (walking) and sitting down in the dining room. There was no POC identified in Patient 2’s home. During an interview on 1/16/2026 at 10:21 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated a copy of POC and medication profile should be available at the patient’s home. The DPCS stated that it is important to have the POC in patient’s home to make sure patients and their families are aware of the care and services patients are receiving. During a review of the agency’s policy and procedure titled, “Care Planning Process” not dated, the policy and procedure indicated the organization shall provide the patient and caregiver with a copy of written instructions outlining: any treatments, to be administered by the organization, including therapy services and any other pertinent instructions related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor ID # 43979, Health Facilities Evaluator Nurse Surveyor ID # 43929, Health Facilities Evaluator Nurse Census: 2 Unduplicated admissions:18 Sample Size: 7 Home Visits: 2 Closed Record review: 5 The following three Conditions of Participation (COP) were not met: 484.50 Condition of participation: Patient Rights 484.55 Condition of Participation: Comprehensive Assessment of Patients 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure that the Condition of Participation regarding Patients’ rights was met as follows: 1. The Home Health Agency (HHA) failed to provide the Patient’s Rights notice in advance, and in a language written that is understandable by persons who have limited english proficiency for one of seven sampled patients (Patient 1). This deficient practice had the potential for patients not being able to understand their rights as a patient while under the agency's care. (Refer to G412). 2. The HHA failed to provide the contact information of the HHA administrator, including the administrator’s name, business address, and business phone number to receive complaints, for two of seven sampled patients (Patient 1 and Patient 4). This deficient practice resulted in the patients not having the necessary information to voice their concerns if an issue should arise during their care. (Refer to G414). 3. The HHA failed to obtain a signature to confirm that he or she has received a copy of the notice of rights and responsibilities for one of seven sampled patients (Patient 1). This deficient practice can result in patients and representatives not understanding their rights and responsibilities as a patient while under the HHA’s care. (Refer to G418). 4. The HHA failed to provide services as outlined in the plan of care for one of seven sampled patients (Patient 2). This deficient practice can affect the quality of care provided to the patients and can result in delayed healing due to missed treatments. (Refer to G436). The cumulative effects of these systemic practices resulted in the HHA’s failure to deliver statutorily mandated compliance with Federal regulations for Patient Rights to ensure the HHA protected and promoted the exercise of these rights. .

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 interview and record review, the Home Health Agency (HHA) failed to provide the Patient’s Rights notice in advance, and in a language written that is understandable by persons who have limited english proficiency for one of seven sampled patients (Patient 1). This deficient practice had the potential for patients not being able to understand their rights as a patient while under the agency's care. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with an unwritten diagnosis. A review of Patient 1’s Electronic Medical Record (EMR) on 10/26/22 did not include a written notice of Patient’s Rights. During a concurrent interview and record review on 10/26/2022 at 11:20 a.m. with the Administrator (ADM), of P1’s EMR. The ADM was not able to locate a Patient Rights consent. During an interview on 10/28/2022 at 3:40 p.m. with the ADM, the ADM stated he visited P1’s home on 10/27/2022. The ADM stated all consents were filled out and signed, including Patient Rights. The ADM stated that the Patient Rights consent was in English and not Mandarin, P1’s language. A review of the HHA’s undated policy and procedure titled, “Medical Record Content” indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain documentation of the receipt of rights and responsibilities and Language and communication needs. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation and all visit reports attached must be submitted the next scheduled workday. A review of the undated HHA’s policy and procedure titled, “Patient Bill of Rights and Responsibilities” indicated, “The Agency will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment. The Agency will provide a verbal notice of patient’s rights and responsibilities in individuals primary or preferred language. The Agency will document that a verbal discussion of rights took place and that the patient was able to confirm his/her understanding of the rights.”

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide the contact information of the HHA administrator, including the administrator’s name, business address, and business phone number to receive complaints, for two of seven sampled patients (Patient 1 and Patient 4). This deficient practice resulted in the patients not having the necessary information to voice their concerns if an issue or any concerns should arise while under the agency’s care. a. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with an unwritten diagnosis. During a concurrent observation, interview, and record review on 10/27/2022 at 3p.m. with Registered Nurse 1 (RN1), of P1’s Home Health (HH) home folder at P1’s home, P1’s HH folder was from a different Home Health Agency 2 (HHA2). RN1 stated, “This folder is the wrong home health folder, it’s a completely different agency. I was not the one that brought or provided that book.” A closer inspection of P1’s HHA2 home folder, indicated the contact information was for that agency and not the current HHA taking care of P1. b. A review of Patient 4’s (P4) profile indicated a SOC of 10/18/22 with a diagnose s that included acute lymphoblastic leukemia (a type of blood cancer). An observation was made during the home visit on 10/28/22, at 1:00 p.m., with Registered Nurse 2 (RN 2). Patient 4 (P4) was observed receiving care. An agency folder was observed at P4’s side. During an interview on 10/28/22, at 1:30 p.m., P4 stated he did not know how to contact the administrator or any agency personnel in case he had complaints or concerns regarding his care. When asked if agency personnel had reviewed the contents of the folder, P4 replied, “She brought it, but didn’t explain what was inside of the binder. I can see there is a lot of stuff, but I don’t know what it’s for.” A review of the HHA’s undated policy and procedure titled, “Medical Record Content” indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain documentation of receipt of rights and responsibilities. A review of the HHA’s undated policy and procedure titled, “Patient Bill of Rights and Responsibilities” indicated, “Patients have the right to make complaints to the Agency and voice and report grievances or complaints.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to obtain a signature to confirm that one of seven sampled patients (Patient 1) had received a copy of the notice of rights and responsibilities. This deficient practice had the potential to result in patients and representatives not understanding their rights and responsibilities as a patient while under the HHA’s care. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with an unwritten diagnosis. A review of Patient 1’s Electronic Medical Record (EMR) on 10/26/22 did not include a written notice of Patient’s Rights. During an interview and concurrent record review on 10/26/2022 at 11:20 a.m., the Administrator (ADM) was unable to locate P1’s electronic medical record (EMR) for Patient Rights consent. During an interview on 10/28/2022 at 3:40 p.m. the ADM stated that he visited P1’s home on 10/27/2022 and stated all the consents were filled out and signed, including Patient Rights. ADM stated that the Patient Right consent was in English and not Mandarin (Asian language), P1’s language. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation, ensure all visit reports are attached, and must be submitted the next scheduled workday. A review of the HHA’s undated policy and procedure titled, “Patient Bill of Rights and Responsibilities” indicated, the Agency will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment.”

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide services as outlined in the plan of care for two of seven sampled patients, (Patient 2 and Patient 4). This deficient practice has the potential to affect the quality of care provided to patients and can result in a delayed healing due to missed treatments. a. A review of Patient 2’s (P2) “Patient Profile” indicated P2 was a 74-year-old female admitted to the home health agency (HHA) on 5/5/2022 with a primary diagnosis of Malignant neoplasm of overlapping sites of right breast (breast cancer) and a discharge date of 5/10/2022. During an interview on 10/27/2022 at 1:20 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that they do not have or use a Medication Administration Record (MAR) for their patients. The DPCS also stated that the nurse normally documents in the notes on the day the medication was administered. The DPCS was unable to find a note while looking into P2’s Electronic Medical Record (EMR), regarding the Heparin that was administered from 5/6/2022 to 5/9/2022, and stated its only in the discharge Oasis.” The DPCS stated, “She wrote that she only gave 2.5 ml (milliliters) of heparin mixed with 2.5 ml NS. She didn’t give the right amount of heparin flush.” A review of P2’s “Physician Orders” dated 5/5/2022 indicated to infuse Normal Saline followed by 5ml (milliliters) of Heparin (Blood thinner medication) 100 units/ml after the last normal saline flush. A review of P2’s “Patient Medication Profile” indicated “Flush Port-A-Catheter with 5ml of Heparin 100 units/ml after last normal saline flush. A review of P2’s “Home Health Certification and Plan of Care” for period 5/5/2022 to 7/3/2022 indicated “Flush Port-A-Catheter with 5ml of Heparin 100 units/ml after last normal saline flush”. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/7/2022 did not indicate a documentation of 5ml of Heparin 100 units/ml after last normal saline flush. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/8/2022 did not indicate a documentation of the 5ml of Heparin 100 units/ml after last normal saline flush. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/9/2022 did not indicate a documentation of the 5ml of Heparin 100 units/ml after the last normal saline flush. A review of Patient 2’s (P2) Discharge Assessment dated 5/10/2022 indicated “Flushed the tubing with 2.5ml normal saline mixed with 2.5ml of Heparin 100 units/ml.” b. A review of Patient 4’s (P4) profile indicated a SOC of 10/18/22 with diagnoses including acute lymphoblastic leukemia (a type of blood cancer). During an interview on 10/26/22, at 11:44 a.m., the administrator (ADM) stated P4 did not have a plan of care documented in his medical record. During an interview on 10/28/22, at 3:35 p.m., the Director of Patient Care Services (DPCS) stated the referral order indicated to flush the PICC (Peripherally Inserted Central Catheter, a type of tube inserted in the upper vein in the arm used to give medication) with 5 ml (a unit of measurement, milliliters) of heparin (a medication used to prevent blood from clotting). During a concurrent record review on 10/28/22, at 3:35 p.m. of P4’s medical record titled, “RN IV Visit”, dated 10/18/22 with the DPCS. The form indicated “flushed with 3 ml of Heparin 100 units/ml observing universal precautions.” When asked, the DPCS stated the nurse did not follow the order on the referral. The DPCS stated it was important to follow the order to make sure the patient is getting the right medication for their safety. The DPCS stated the nurse needed to give an additional 2 ml, placing the patient at risk of the PICC line clotting resulting in delay in treatment, risk of hospitalization, blood clot formation, and infection. A review of P4’s medical record titled, “Prescriber Orders”, dated 10/6/22, indicated, the flushing protocol is to flush the used lumen (the port used to give medication) with normal saline (a type of fluid) 10 ml (milliliters, a unit of measurement) and lock (the unused port) with Heparin 5 ml as directed by MD, if applicable. A review of the HHA’s policy and procedure titled, “Care Planning Process” revised February 2021, indicated in order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems. The Agency will utilize date/information gathered during patient assessments in the care planning process. Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation, ensure all visit reports attached and must be submitted the next scheduled workday. A review of the HHA’s p undated policy and procedure titled, “Physician/Practitioner Orders – Verbal Orders” indicated dugs and treatments are administered by the Agency staff only as ordered by the physician/practitioner. A review of the HHA’s undated policy and procedure titled, “Patient Bill of Rights and Responsibilities” indicated Patients have the right to receive all services in the plan of care.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to ensure the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) was completed no later than five calendar days from the start of care, for two of seven sampled patients, (Patients 1 and Patient 4).This deficient practice had the potential that patients will not receive the care and services necessary for their complete healing when needs are not assessed and identified. (Refer to G520). 2. The HHA failed to ensure that all current medications and treatments were reviewed and documented, and medication lists were available for two of seven sampled patients (Patients 1 and Patient 4) This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health services. .

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 Home Health Agency (HHA) failed to ensure the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) was completed no later than 5 calendar days from the start of care for two of seven sampled patients, (Patients 1 and Patient 4). This deficient practice had the potential that patients will not receive the care and services necessary for their complete healing when needs are not assessed and identified. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with unwritten diagnoses. A review of Patient 1’s Electronic Medical Record (EMR) on 10/26/22 did not include a comprehensive assessment (an assessment focusing on the physical, emotional, and psychosocial needs of the patient). During an interview on 10/26/22, at 11:15 a.m., the Administrator (ADM) stated the comprehensive assessment was to be completed within seven days of the start of care. The ADM stated it was important to complete the assessment because it tells the agency which services the patient is supposed to receive. The ADM stated the assessment was supposed to be completed and documented in the medical record of P1 and P4. The ADM did not provide an explanation on why it was not completed. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation, ensure all visit reports are attached and must be submitted the next scheduled workday. A review of the HHA’s undated policy and procedure titled, “Initial Assessment/Comprehensive Assessment” indicated each patient admitted by the Agency will have appropriate initial assessments performed and documented. A review of the undated HHA’s policy and procedure titled, “Medical Record Content” indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain the: initial and ongoing assessments, including a comprehensive assessment. A review of the HHA’s undated policy and procedure titled, “Medical Record Entries and Authentications” indicated all entries in patient records will be complete. A review of Patient 4’s (P4) profile indicated a SOC of 10/18/22 with diagnoses including acute lymphoblastic leukemia (a type of blood cancer). A review of Patient 4’s medical record on 10/26/22 did not include a comprehensive assessment

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure that all current medications and treatments were reviewed and documented, and medication lists were available for two of seven sampled patients (Patients 1 and Patient 4). This deficient practice placed the patients at risk of adverse drug-to-drug interaction and harm by not knowing which medications the patients were taking. a. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with an unwritten diagnosis. A review of Patient 1’s medical record on 10/26/22 did not include a medication list (a document noting the medications the patient is taking). A review of P1’s “Physician Order” dated 10/21/2022 indicated P1 was to receive Jevity 1.2 Cal with a cyclic goal of 100ml (milliliters)/hr. (hour) for 18 hours with free water 120ml 6 times per day for six months. During an interview on 10/26/22, at 11:44 a.m., the administrator (ADM) stated Patient 1 did not have a medication profile in the medical record. The ADM did not provide a reason why the medication profile did not reflect the medications the patients were taking. During a home visit observation on 10/27/22, at 3 p.m. with Registered Nurse 1 (RN 1), and Patient 1’s medications review, P1 was taking the following medications: 1. Amlodipine 2. Atorvastatin 3. Lisinopril 4. Eliquis 5. Sucralfate 6. Jevity 1.2 Cal 100ml/hr. x 18 hours with free water 120ml 6x per day. When asked, RN1 stated, “It is important to have the plan of care and a list of his medications so that we all know what the patients’ treatment is”. RN1 stated that she does not know why, the admitting nurse did not write the medications. She should have. RN1 assessed P1’s gastrostomy tube and asked about his feeding regimen. b. A review of Patient 4’s (P4) profile indicated a SOC of 10/18/22 with diagnoses including acute lymphoblastic leukemia (a type of blood cancer). A review of Patient 4’s (P4) medical record on 10/26/22 did not include a medication list (a document noting the medications the patient is taking). During an interview on 10/26/22, at 11:44 a.m., the administrator (ADM) stated, P4 did not have a medication profile in the medical record. The ADM did not provide a reason why the medication profile did not reflect the medications the patients were taking. During an observation at the home visit on 10/28/22, at 1:00 p.m., with Registered Nurse 2 (RN 2), P4’s medications were reviewed with a medication list brought by RN 2. During an interview on 10/28/22, at 1:23 p.m., RN 2 stated there was no medication profile or any medications listed in P4’s home. There was supposed to be a medication list at the patient’s home. During an interview on 10/28/22, at 3:05 p.m., the Director of Patient Care Services (DPCS), stated the medication list is supposed to be created at the start of care. The DPCS also stated a medication list is important to make sure medications are correct and are taken correctly. A review of the undated HHA’s policy and procedure titled, “Medical Record Content”, indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain the following: A current medication profile to include the date and time of administration. The dose, strength, route, time, date and any adverse drug reaction of every dose of medication administered by Agency staff. A review of the undated HHA’s policy and procedure titled, “Medication Reconciliation” indicated at the time of admission, the admitting RN (Registered Nurse) will create and document a complete list of mediations that the patient is taking at home. 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 the home will also be updated. A review of the HHA’s policy and procedure titled, “Patient Admission Criteria” dated February 2021, indicated care follows a written plan of care established during the initial visit. The admitting professional will develop a written medication schedule/instruction. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation, ensure all visit reports are attached and must be submitted the next scheduled workday. A review of the undated HHA’s policy and procedure titled, “Medical Record Entries and Authentications” indicated all entries in the patient records will be complete. A review of the HHA’s policy and procedure titled, “Gastrostomy Tube Feeding” dated 2000, indicated to document the type, amount, and frequency of tube feedings and medications administered on the medication record. Document the following on the visit report: the patients general physical status, including abdominal assessment. Document the type, amount, and frequency of tube feedings and medications administered on the medication record and update the plan of care. A review of the HHA’s policy and procedure titled, “Administration of Intravenous Therapy: General Guidelines” dated 2000, indicated to document the procedure and patient toleration on the visit report. And document any updates to the plan of care on the medication or IV record. A review of the HHA’s undated policy and procedure titled, “Patient Bill of Rights and Responsibilities” indicated, patients have the right to receive all services in the plan of care and be informed of patient medication schedules, and treatments to be administered by Agency staff. A review of the HHA’s undated policy and procedure titled, “Medication Administration” indicated staff will use the information from the medication monitoring to assess.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: 1.The Home Health Agency (HHA) failed to ensure plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) were developed for two of seven sampled patients (Patients 1 and Patient 4). This failure had the potential to result in patients not receiving the care and services needed which can affect the quality of care necessary to maintain the highest practicable physical, mental, and psychosocial well-being of the affected patients. (Refer to G572). 2. The HHA failed to ensure pertinent information necessary were included in the plan of care for two of seven sampled patients, (Patient 1 and Patient 4). This failure had the potential to result in patients’ needs and services not identified, and not provided, which can affect the quality of care necessary to maintain the highest practicable mental, physical and psychosocial well-being of the patients under the agency’s care. (Refer to G574). 3. The HHA failed to ensure the correct amount of anticlotting medication was administered to the Port-A-Cath (a device used to draw blood and give treatment, including administration of intravenous fluids and medications) as ordered by the physician for two of seven sampled patients, (Patient 2 and Patient 4). This deficient practice places the port-a-cath at risk for clotting which can result in the delay of the administration of treatment and can affect the healing of the affected patients. (Refer to G580). 4. The HHA failed to ensure a written information was provided regarding the plan of care for two of seven patients (Patient 1 and Patient 4). This deficient practice resulted in patients not knowing their care team or their treatment course. (Refer to G612). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure a plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) were developed for two of seven sampled patients (Patients 1 and Patient 4). This failure had the potential to result in patients not receiving the care and services needed which can affect the quality of care necessary to maintain the highest practicable physical, mental, and psychosocial well-being of the affected patients. b. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with an unwritten diagnosis. A review of Patient 1’s Electronic Medical Record (EMR) on 10/26/22 did not include a Home Health Certification and Plan of Care. During an interview on 10/26/22, at 11:15 a.m., the administrator (ADM) stated the plan of care was supposed to be completed within seven days of the start of care. The ADM also stated it was important to have a plan of care because it tells the agency which services the patient is to receive. During an interview on 10/26/22, at 11:44 a.m., the ADM stated Patient 1 and Patient 4 did not have a plan of care in the medical record. When asked, the ADM did not provide a reason why the plan of care was not in the medical record. A review of the HHA’s undated policy and procedure titled, “Medical Record Content” indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain an initial and ongoing assessments. A review of the HHA’s policy and procedure titled, “Care Planning Process” revised February 2021, indicated in order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems. The Agency will utilize the date information gathered during patient assessments in the care planning process. The patient care plan for Skilled Nursing will be an Initial care plan by CMS (Centers for Medicare/Medical Services) #485 Plan of Care and Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized. A review of the HHA’s policy and procedure titled, “Patient Admission Criteria” dated February 2021, indicated care follows a written plan of care established during the initial visit, and the admitting professional will review the plan of care with the patient/caregiver. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation” revised October 2017 indicated the agency will ensure the timely and proper submission of patient documentation and ensure all visit reports are attached and must be submitted the next scheduled workday. A review of the HHA’s undated policy and procedure titled, “Medical Record Entries and Authentications” indicated all entries in patient records will be complete. A review of the HHA’s undated policy and procedure titled, “Patient Bill of Rights and Responsibilities” indicated Patients have the right to receive all services in the plan of care. a. A review of Patient 4’s profile indicated a SOC of 10/18/22 with diagnoses that included acute lymphoblastic leukemia (a type of blood cancer). A review of Patient 4’s medical record on 10/26/22 did not include a plan of care was formulated.

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 Home Health Agency (HHA) failed to ensure pertinent information necessary were included in the plan of care for two of seven sampled patients, (Patient 1 and Patient 4). This failure had the potential to result in patients’ needs and services not identified, and not provided, which can affect the quality of care necessary to maintain the highest practicable mental, physical and psychosocial well-being of the patients under the agency’s care. b. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with an unwritten diagnosis. A review of P1’s “Home Health Certification and Plan of Care” from 10/21/2022 to 12/19/2022 indicated there was no written primary diagnosis, DME (Durable Medical Equipment), Nutritional requirement, Functional Limitations, Mental status, Prognosis, order for discipline and treatment, goals/rehabilitation potential, nurses’ signature, or attending physician signatures. During an interview on 10/26/22, at 11:15 a.m., the administrator (ADM) stated the plan of care was to be completed within seven days of the start of care. The ADM also stated it was important to have a plan of care because it tells the agency which services the patient is supposed to receive. During an interview on 10/26/22, at 11:44 a.m., the administrator (ADM) stated Patient 1 and Patient 4 did not have a plan of care in the medical record. When asked, the ADM did not provide a reason why the plan of care was not in the medical record. A review of the HHA’s undated policy and procedure titled, “Medical Record Content”, indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain an initial and ongoing assessments and goals in the patient’s plans of care. A review of the HHA’s policy and procedure titled, “Care Planning Process” revised February 2021, indicated in order to assure that care provided is appropriately planned to meet each patient’s specific needs and problem care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized to include problems and needs, goals, specific care or services to be provided including frequency, type, and duration, Implementation of actions and interventions, and review and revision as indicated. A review of the HHA’s policy and procedure titled, “Patient Admission Criteria” dated February 2021, indicated care follows a written plan of care established during the initial visit. The admitting professional will review the plan of care with the patient/caregiver. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation, ensure all visit reports are attached and must be submitted the next scheduled workday. A review of the HHA’s policy and procedure titled, “Medical Record Entries and Authentications” undated indicated all entries in patient records will be complete. A review of the HHA’s undated policy and procedure titled, “Patient Bill of Rights and Responsibilities” indicated, “Patients have the right to receive all services in the plan of care. To be informed of visit schedule and frequency of patient medication schedule, treatments to be administered by Agency staff, and the name of the clinical manager. A review of Patient 4’s medical record on 10/26/22, titled, “Home health Certification and Plan of Care” for certification period 10/18/22-12/16/22, did not include: DME (Durable Medical Equipment), Nutritional requirement, Functional Limitations, Mental status, Prognosis, order for discipline and treatment, goals/rehabilitation potential, nurses’ signature, or attending physician signatures.

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 Home Health Agency (HHA) failed to ensure the correct amount of anticlotting medication was administered to the Port-A-Cath (a device used to draw blood and give treatment, including administration of intravenous fluids and medications) as ordered by the physician for two of seven sampled patients, (Patient 2 and Patient 4). This deficient practice places the patients’ port-a-cath at risk for clotting which can result in the delay of the administration of the treatment and can affect the healing of the affected patients. a. A review of Patient 2’s (P2) “Patient Profile” indicated P2 was a 74-year-old female admitted to the home health agency (HHA) on 5/5/2022 with a primary diagnosis of Malignant neoplasm of overlapping sites of right female breast (breast cancer). A review of P2’s “Physician Orders” dated 5/5/2022 indicated “normal saline (a type of fluid), followed by 5ml (milliliters) of Heparin (anticlotting medication) 100 units/ml after last normal saline flush.” A review of P2’s “Patient Medication Profile” indicated to flush the Port-A-Catheter (a device used to draw blood and give treatment, including intravenous fluids and medications) with 5 ml of Heparin 100 units/ml after the last normal saline flush. A review of P2’s “Home Health Certification and Plan of Care” for period 5/5/2022 to 7/3/2022 indicated to flush the Port-A-Catheter with 5ml of Heparin 100 units/ml after the last normal saline flush. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/7/2022 did not indicate documentation the 5ml of Heparin 100 units/ml was flushed after the last normal saline flush. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/8/2022 did not indicate documentation the 5ml of Heparin 100 units/ml was flushed after the last normal saline flush. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/9/2022 did not indicate documentation the 5ml of Heparin 100 units/ml was flushed after the last normal saline flush. b. A review of Patient 4’s (P4) profile indicated a SOC of 10/18/22 with diagnoses that included acute lymphoblastic leukemia (a type of blood cancer). A review of P4’s medical record titled, “Prescriber Orders”, dated 10/6/22, indicated to flush the used lumen (the port used to give medication) with normal saline 10 ml and lock (the unused port) with Heparin 5 ml as directed by MD, if applicable. During an interview on 10/28/22, at 3:35 p.m., the Director of Patient Care Services (DPCS) stated the referral order indicated to flush the PICC (Peripherally Inserted Central Catheter, a type of tube inserted in the upper vein in the arm used to give medication) with 5 ml of heparin. On 10/28/22, at 3:35 p.m., during an interview and concurrent record review with the DPCS, P4’s medical record titled, “RN IV Visit”, dated 10/18/22, indicated the PICC was flushed with 3 ml of Heparin 100 units/ml observing universal precautions. The DPCS stated the nurse did not follow the physician’s order on the referral which was 5 ml. The DPCS also stated it was important to follow the order to make sure the patient is getting the right medication for their safety. The DPCS stated the nurse did not give the 5 ml order of heparin. This placed the patient’s PICC line at risk for clotting which can result in a delay in the treatment, risk of hospitalization, blood clot formation, and infection. A review of the undated HHA’s policy and procedure titled, “Administration of Intravenous Therapy: General Guidelines” dated 2000, indicated to document on the visit report, the procedure and patient toleration. Document the following on the medication or IV record: solution infused, expiration date, the amount and hourly rate for each 24-hour volume, IV medications and initials of the person who hung the infusion. Update plan of care. A review of the HHA’s undated policy and procedure titled, Physician/Practitioner Orders – Verbal Orders”, indicated, “drugs and treatments are administered by the agency staff only as ordered by the physician/practitioner. A review of the HHA’s undated policy and procedure titled, “Medication Administration” indicated, “Medication and treatments are administered as ordered by the physician.

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 observation, interview, and record review, the Home Health Agency (HHA) failed to provide written information regarding the plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for two of seven sampled patients (Patient 1 and Patient 4). This deficient practice resulted in patients not knowing their care team or their treatment course. b. A review of Patient 4’s profile indicated a SOC of 10/18/22 with diagnoses including acute lymphoblastic leukemia (a type of blood cancer). A review of Patient 4’s medical record on 10/26/22 did not include a plan of care. During an interview on 10/26/22, at 11:15 a.m., the administrator (ADM) stated the plan of care was supposed to be completed within 7 days of the start of care. The ADM stated it was important to have a plan of care because it tells the agency which services the patient is supposed to receive. During an interview on 10/26/22, at 11:44 a.m., the administrator (ADM) stated Patient 4 did not have a plan of care in the medical record. The ADM did not provide a reason why the plan of care was not in the medical record. During an observation of the home visit on 10/28/22, at 1:00 p.m., with Registered Nurse 2 (RN 2), there was no written plan of care at the home. During an interview on 10/28/22, at 1:23 p.m., RN 2 stated a plan of care is supposed to be given by the nurse starting the care. During an interview on 10/28/22, at 3:20 p.m., the Director of Patient Care Services (DPCS) stated it was important for the patient to have a copy of their plan of care, so they are involved with their care and know what to expect. The DPCS stated it was the patients right to know what services they are getting. a. A review of Patient 1’s (P1) “Intake Referral Form” indicated a start of care (SOC) date of 10/21/2022 with diagnoses not written. A review of P1’s “Patient profile” indicated a SOC date of 10/21/2022 with diagnosis not written. A review of P1’s Electronic Medical Record (EMR) on 10/26/22 did not include a plan of care. A review of P1’s “Home Health Certification and Plan of Care” from 10/21/2022 to 12/19/2022 there was no written Primary diagnosis, DME (Durable Medical Equipment), Nutritional requirement, Functional Limitations, Mental status, Prognosis, order for discipline and treatment, goals/rehabilitation potential, nurses signature, or attending physician signatures. During a concurrent observation, interview and record review on 10/27/2022 at 3p.m. with Registered Nurse 1 (RN1), of P1’s Home Health (HH) home folder at P1’s home, P1’s HH folder indicated it had no information regarding P1’s POC. RN1 was unable to locate P1’s POC and stated, “It is important to have the plan of care and a list of his medications so that we all know what the patients’ treatment is”. A review of Patient 4’s profile indicated a SOC of 10/18/22 with diagnoses including acute lymphoblastic leukemia (a type of blood cancer). A review of Patient 4’s medical record on 10/26/22 did not include a plan of care. During an interview on 10/26/22, at 11:15 a.m., the administrator (ADM) stated the plan of care was supposed to be completed within 7 days of the start of care. The ADM stated it was important to have a plan of care because it tells the agency which services the patient is supposed to receive. During an interview on 10/26/22, at 11:44 a.m., the administrator (ADM) stated Patient 1 and Patient 4 did not have a plan of care in the medical record. The ADM did not provide a reason why the plan of care was not in the medical record. A review of the HHA’s policy and procedure titled, “Medical Record Content”, undated, indicated “The Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain the following: initial and ongoing assessments, including comprehensive assessment…” A review of the HHA’s policy and procedure titled, “Care Planning Process” revised February 2021, indicated “In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems… Care planning for each patient will be individualized to include problems and needs, goals based on problems, needs, conditions, wishes…” A review of the HHA’s policy and procedure titled, “Patient Admission Criteria” dated February 2021, indicated “Care follows a written plan of care established… During the initial visit, the admitting professional will: Review the plan of care with the patient/caregiver…” A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated “The agency will ensure the timely and proper submission of patient documentation…”

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency Administrator failed to ensure the individualized plan of care (POC) was developed for one of seven sampled patients (Patient 4). This deficient practice resulted in errors in the care received due to staff not having a written Plan of Care to reference when providing care. b. A review of Patient 4’s (P4) profile indicated a SOC of 10/18/22 with diagnoses including acute lymphoblastic leukemia (a type of blood cancer). During an interview on 10/26/22, at 11:44 a.m., the administrator (ADM) stated P4 did not have a plan of care documented in his medical record. During an interview on 10/28/22, at 3:35 p.m., the Director of Patient Care Services (DPCS) stated the referral order indicated to flush the PICC (Peripherally Inserted Central Catheter, a type of tube inserted in the upper vein in the arm used to give medication) with 5 ml (a unit of measurement, milliliters) of heparin (a medication used to prevent blood from clotting). During a concurrent interview and record review on 10/28/22, at 3:35 p.m., P4’s medical record titled, “RN IV Visit”, dated 10/18/22, was reviewed with the DPCS. The form indicated “…flushed with 3 ml of Heparin 100 units/ml observing universal precautions.” The DPCS stated the nurse did not follow the order on the referral. The DPCS stated it was important to follow the order to make sure the patient is getting the right medication for their safety. The DPCS stated the nurse needed to give an additional 2 ml, placing the patient at risk of the PICC line clotting resulting in delay treatment, risk of hospitalization, blood clot formation, and infection. A review of P4’s medical record titled, “Prescriber Orders”, dated 10/6/22, indicated, “…Flushing protocol flush used lumen (the port used to give medication) with normal saline (a type of fluid) 10 ml (milliliters, a unit of measurement) and lock (the unused port) with Heparin 5 ml as directed by MD, if applicable.” A review of the HHA’s policy and procedure titled, “Care Planning Process” revised February 2021, indicated “In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems.... Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized…” A review of the HHA’s “Administrators Job Description” undated indicated, “Uniformly enforces policies and procedures… Evaluates effectiveness and efficiency of the Agency”.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to document medication administration, interventions and the response for one of seven sampled patients (Patient 2). This deficient practice had the potential to result in patients and care staff not knowing if the patient received the prescribed treatment as ordered. A review of Patient 2’s (P2) “Patient Profile” indicated P2 was a 74-year-old female admitted to the HHA on 5/5/2022 with a discharge date of 5/10/2022 and a primary diagnosis of Malignant neoplasm of overlapping sites of right female breast (breast cancer). A review of P2’s “Physician Orders” dated 5/5/2022 indicated to infuse normal Saline followed by 5ml (milliliters) of Heparin (Blood thinner medication) 100 units/ml after last normal saline flush.” A review of P2’s “Patient Medication Profile” indicated “Flush Port-A-Catheter with… 5ml of Heparin 100 units/ml after last normal saline flush”. A review of P2’s “Home Health Certification and Plan of Care” for period 5/5/2022 to 7/3/2022 indicated to flush the Port-A-Catheter with 5ml of Heparin 100 units/ml after last normal saline flush”. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/7/2022 indicated there was no documentation of the 5ml of Heparin 100 units/ml after the last normal saline flush. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/8/2022 indicated there was no documentation of the 5ml of Heparin 100 units/ml after the last normal saline flush. A review of P2’s “Skilled Nursing Progress Visit” note dated 5/9/2022 indicated there was no documentation of the 5ml of Heparin 100 units/ml after the last normal saline flush. A review of Patient 3’s (P3) Discharge Assessment dated 5/10/2022 indicated to flush the tubing with 2.5ml of normal saline mixed with 2.5ml of Heparin 100 units/ml. During an interview on 10/27/2022 at 1:20 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that they do not have or use Medication Administration Records (MAR) for their patients. DPCS stated that the nurse normally documents under notes the day and the medication administered. DPCS while looking into P2’s Electronic Medical Record (EMR) stated that she was unable to find a note stating that Heparin was administered from 5/6/2022 to 5/9/2022, “Only the discharge Oasis”. The DPCS stated she wrote that she only gave 2.5ml of heparin mixed with 2.5ml NS and didn’t give the right amount of heparin flush. A review of the HHA’s policy and procedure titled, “Administration of Intravenous Therapy: General Guidelines” dated 2000, indicated to document the procedure and patient toleration on the visit report and document the following on the medication or IV record: solution infused, expiration date, the amount and hourly rate for each 24-hour volume, IV medications and initials of the person who hung the infusion and update the plan of care.” A review of the HHA’s policy and procedure titled, “Central Venous Catheter Management” dated 2000, indicated to document the following on the visit report: the procedure and patient toleration, IV medications and solutions infused on the medication or IV record and update plan of care.” A review of the HHA’s undated policy and procedure titled, “Medical Record Entries and Authentications” indicated that all entries in the patient records will be complete. A review of the HHA’s undated policy and procedure titled, “Medical Record Content”, indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain the following: A current medication profile to include… the date and time of administration. The dose, strength, route, time, date and any adverse drug reaction of every dose of medication administered by Agency staff. A review of the HHA’s policy and procedure titled, “Timely Submission of Patient Documentation”, revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation, ensure all visit reports are attached, and must be submitted the next scheduled workday. A review of the HHA’s undated policy and procedure titled, “Medication Administration” indicated medication and treatments are administered as ordered by the physician. Patients will be assessed and reassessed on an ongoing basis for medication effectiveness and actual or potential drug related problems. Staff will use the information from medication monitoring to assess. In the event of a medication error or adverse drug reaction, the patient’s physician is to be notified immediately.”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to send all necessary medical information to the primary care practitioner within five days of discharge for three of seven sampled patients (Patient 3, Patient 6, and Patient 7). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. a. A review of Patient 3’s (P3) “Patient Profile” indicated P3 was a 68-year-old male admitted to HHA on 5/18/2022 with a discharge date of 6/7/2022 and a primary diagnosis of Malignant neoplasm of pyloric antrum (stomach cancer). During a concurrent interview and record review on 10/28/2022 at 3:49 p.m. with the Director of Patient Care Services (DPCS) of P3’s Electronic Medical Record (EMR), the DPCS stated that they usually inform the doctor of the patients discharge via a phone call and fax the patients discharge summary within five days of discharge. The DPCS stated, “It is important so that the physician knows we were able to provide the ordered care and if there is anything that was missing, he would let us know ahead of time. We document under the orders; the telephone order and the Discharge Oasis specifies that we notified the physician, and that the summary was sent.” While looking at P3’s EMR the DPCS stated, “There is no documentation that a discharge summary was sent to (P3’s) MD. The discharge summary is not completed…” A review of P3’s Discharge assessment note dated 6/7/2022 indicated there was no signature on note. b. A review of Patient 6’s (P6) profile indicated a start of care date of 1/30/22, with diagnoses that included acute cholecystitis (inflammation of the gall bladder). Further review of the record indicated P6 was discharged from the HHA on 2/6/22. A review of P6’s medical record titled, “Physician Orders”, dated 2/6/22, indicated “Reasons: goals met, IV (intravenous medications) complete…discharge patient from Lifelink Health Prov.”. Further review of the record did not indicate a discharge summary was sent to the doctor within five days of P6’s discharge date. c. A review of Patient 7’s (P7) profile indicated a start of care date of 5/13/22 with diagnoses including aftercare following a joint replacement surgery. Further review of the record indicated P7 was discharged from the HHA on 6/2/22. A review of P7’s medical record titled, “Physician Orders”, dated 6/2/22, indicated “Reasons: goals met…discharge patient from Lifelink health providers.”. Further review of the record did not indicate a discharge summary was sent to the doctor within five days of P7’s discharge date. A review of the HHA’s”, undated, policy and procedure titled, “Medical Record Content indicated the Agency will provide an accurate and current medical record for every patient seen by the Agency. Each medical record will contain the following: Notification to the prescribing physician of patient discharge and a complete discharge summary when the patient is transferred to another organization. A review of the HHA’s undated policy and procedure titled, “Discharge Criteria and Planning” indicated “Physician and other care providers will be informed and knowledgeable of discharge. The Agency will 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…health care practitioner…” A review of the HHA’s undated policy and procedure titled, “Discharge Summary” indicated, “A discharge summary will be completed for all patients discharged from the Agency. A discharge summary will be sent within five business days of patient discharge to the primary care practitioner.”