Every finding on record at Maxim Healthcare Services, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey, conducted on 1/14/2025 to 1/16/2025. Complaint Number: 111975 Unduplicated admissions: 87 Active patients: 81 Sample Size: 7 Home Visits: 3 All COPs were met

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to update the comprehensive assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) within 48 hours of the patient’s return to home from a hospital admission, for one of seven sampled patients (Patient 1). This deficient practice had the potential to not to meet Patient 1’s needs. Findings: During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 1 was admitted on 6/18/2024, with a diagnosis that includes short bowel syndrome with colon in continuity (a rare condition that occurs when a patient has less than 200 cm [centimeter, a unit of measure] of small intestine remaining, but still has a colon [also known as the large intestine, is a tube-shaped organ that removes water and nutrients from food waste and passes it to the rectum]), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a review of Patient 1’s Resumption of Care (ROC) Visit Note, dated 1/6/2025 and conducted by Registered Nurse 1 (RN 1), the ROC indicated Patient 1 was admitted to GACH 1 (General Acute Care Hospital) on 12/13/2024 for abnormal laboratory results and was discharged back to home on 12/26/2024. During an interview with RN 1, on 1/16/2025 at 11:20 a.m., RN 1 stated Patient 1 came back home from a hospital admission on 12/26/2024. RN1 stated she conducted the ROC visit to update Patient 1’s comprehensive assessment on 1/6/2025. RN 1 stated the delay on the ROC visit assessment was due to lack of communication from Patient 1’s family member. During an interview, on 1/16/2025, at 12:45 pm., with the Director of Patient Care Services (DPCS), the DPCS stated an update to the comprehensive assessment should be conducted within 48 hours of patient’s return to the home from a hospital admission of 24 hour or more. DPCS stated and acknowledged the findings. During a review of the agency’s policy and procedure (P&P) titled, Reassessments/Recertifications, revised date 10/4/2024, the P&P indicated a comprehensive reassessment and recertification assessment is conducted by a qualified clinician to identify the patient’s current health status and continued needs for home health services. A follow-up comprehensive assessment is conducted by a qualified clinician within 48 hours of a patient’s discharge from the hospital, or within 48 hours of agency knowledge of the hospital discharge, or on the date as ordered by the physician. This assessment is referred to as a Resumption of Care (ROC).

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 observation, interview, and record review, the Home Health Agency (HHA) failed to ensure interventions for patient/caregiver teaching on checking placement prior to gastrostomy (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food) feeding, was implemented in accordance with the plan of care for one of seven sampled patients (Patient 5). This deficient practice placed Patient 5 at risk for G-tube complications such as the G tube being misplaced from the stomach and could lead to aspiration pneumonia (lung infection that occurs when food or stomach contents enter the lungs). During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 3/5/2020, with diagnoses including encounter for attention to gastrostomy and disorder of bone density and structure. During a review of Patient 5's Home Health Certification and Plan of Care (POC) for the certification period starting from 12/9/2024 to 2/5/2025, the POC included an order for the licensed vocational nurse (LVN) to provide skilled nursing at 144-180 hours per month for the 60-day certification period, and registered nurse (RN) supervisory visit at least once every 60 days and two visits as needed for supervision, case management and resumption of care. The POC included a G-tube enteral (directly to the stomach) feeding order of Peptamen Junior (formula) one could be mixed with Duocal (high calorie) 75 grams with water to equal 15 ounces, and 450 milliliters to give by G-tube, and to educate patient/caregiver on all care including G-tube placement check for proper placement prior to feeding. On 1/15/2025, at 11 a.m., a home visit was conducted at Patient 15's residence with Registered Nurse (RN 1). Patient 5 was observed with a G-tube (Mic-Key button size 14 french) located at mid stomach area dry and intact. On 1/15/2025, at 11:30 a.m., during an interview with family member (FM 1), she stated she provided the enteral feeding, and that she (FM1) was not instructed by the visiting nurse to check G-tube placement before providing feedings to Patient 5. During an interview, on 1/16/2025, at 11:45 a.ml, with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse should have provided patient care teaching on G-tube placement to FM1 to check prior to feeding to ensure that the tube was properly positioned in the stomach to prevent aspiration. During a review of the agency’s policy and procedure (P&P) titled, Home Health Certification and Plan of Care, dated 7/9/2018, the P&P indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s). The Plan of Care shall include, but not limited to identified patient problems to include diagnoses and surgical procedures

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 delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (POC) that included problems, goals and interventions for one of seven sampled patients (Patient 2), who had a diagnosis of epilepsy (a chronic brain disorder that causes seizures, which are brief episodes of abnormal electrical activity in the brain that causes a temporary change in behavior, movement, or consciousness) and was taking anti-seizure medications. This failure had the potential to result in Patient 2 not receiving the identified needs and services, which could lead to a decline in his health status and/or injury. Findings: During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 2 was admitted on 12/14/2000, with a diagnosis that includes moderate intellectual disabilities, encounter for attention to gastrostomy (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and epilepsy, unspecified. During a review of Patient 2's POC for certification period from 12/10/2024 to 2/7/2025, included an order for the licensed vocational nurse (LVN) to provide skilled nursing at 45-56 hours per week for the 60-day certification period, and registered nurse (RN) supervisory visit at least once every 60 days and two visits as needed for supervision, case management and resumption of care. The POC indicated an order to administer two anti-seizure medications to Patient 2: Oxcarbazepine 300 milligrams(mg)/5 milliliter (ml) oral suspension give 6ml/360mg two times daily via g-tube, and Klonopin 0.5 mg tablet give 1 tablet two times daily via g-tube. The POC indicated there were no nursing precautions for seizures protecting the patient from injury and keeping their airway clear. During an interview, on 1/16/2025 at 12:45 pm., with the Director of Patient Care Services (DPCS), the DPCS stated Patient 2’s POC should have included seizure precautions to keep the patient safe and free from injury in case of a seizure activity. During a review of the agency’s policy and procedure (P&P) titled, Home Health Certification and Plan of Care, dated 7/9/2018, the P&P indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s). The Plan of Care shall include, but not limited to identified patient problems to include diagnoses and surgical procedures.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview, and record review the Home Health Agency (HHA) failed to notify the physician for one of seven sampled patients (Patient 4) of a change of condition. This failure had the potential to result in the delay to provide further treatment and interventions for Patient 4. During a review of Patient 4’s Personal Information, the Personal Information indicated a start of care date of 11/16/2022 with a primary diagnosis of Guillain-Barre syndrome (a condition in which the immune system attacks the nerves). During a review of Patient 4's Home Health Certification and Plan of Care (POC) for the certification period starting from 1/4/2025 to 3/4/2025, the POC indicated an order for the licensed vocational nurse (LVN) to provide skilled nursing at 48-56 hours per week for the 60-day certification period, and Registered Nurse (RN) supervisory visit at least once every 60 days and 2 visits as needed for supervision, case management and resumption of care. The POC included an order for skilled nurse to observe and monitor client each shift and as needed for any changes in patient condition, and to report all adverse changes to the physician. During a review of Patient 4's Skilled Nursing Note dated 1/6 and 1/12/2025, the Skilled Nursing Note indicated Patient 4 had a productive cough. The Skilled nursing Notes did not indicate the HHA notify Patient 4's physician. During an interview on 1/16/2025, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated there was no documented communication note found that the visiting nurse notified the physician of Patient 4's existing productive cough episodes. During a review of facility’s policy and procedure titled “Ongoing Evaluation” revised 7/1/2022, indicated “Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. The patient’s physician will be contacted on the same day when any of the following occur: Changes in the patient’s condition. Changes that have occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations).”

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted on 10/31/2023 to 11/3/2023. Complaint Number:102279 Representing the California Department of Public Health: Surveyor #22303, Health Facilities Evaluator Nurse Surveyor #44186, Health Facilities Evaluator Nurse Active Patients: 84 Unduplicated Admissions: 98 Sample Size - 7 Home Visits - 3 On 11/1/2023 at 1:31 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator and the Director of Patient Care Services related to the home health agency’s failure to ensure Patient 1 was treated with dignity and respect and had the right to be free from physical abuse from Licensed Vocational Nurse 1 (LVN1). On 11/2/2023 at 3:02 p.m. the home health agency sent the IJ Removal Plan by email. The survey team reviewed and notified the ADM and the DPCS, the IJ Removal Plan was not accepted on 11/3/2023 at 9:59 a.m. On 11/3/2023 at 12 p.m., the agency sent a revised IJ Removal Plan, and was reviewed by the survey team. The survey team notified the DPCS, the IJ Removal Plan was not accepted on 11/3/2023 at 12:15 p.m. On 11/3/2023, at 12:50 p.m., the agency sent a revised IJ Removal Plan, and was reviewed by the survey team. The survey team notified the DPCS, the IJ Removal Plan was not accepted on 11/3/2023 at 2:05 p.m. The IJ was not removed. On 11/3/23 at 4:35 p.m., the survey team completed the survey tasks, and exited with the IJ situation not removed. On 11/13/2023, the agency’s ADM submitted an acceptable IJ removal Plan. On 11/14/2023 at 1:35 pm, the survey team removed the IJ in the presence of the ADM/DPCS and the VP of operations, after reviewing and confirming onsite that the agency implemented the IJ removal plan. The following Condition of Participations not met: 484.50 Patient Rights 484.105 Organization and Administration of Services

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 interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] program) regarding Patient Rights was met as follows: 1. The HHA the failed to ensure one of seven sampled patients (Patient 1) was free from physical abuse from Licensed Vocational Nurse 1 (LVN 1). (Refer to G430) 2. The HHA failed to conduct an complaint investigation regarding mistreatment and physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) by a Licensed Vocational Nurse 1 while doing patient care for one out of 7 sampled patients (Patient 1). (Refer to G482) 3. The HHA failed to document the alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) in their grievance log and its resolution for one out of 7 sampled patients (Patient 1). (Refer to G484) 4. The HHA failed to report an alleged abuse to the Department of Public Health Licensing and Certification unit within 24 hours as per agency’s policy for one out of seven sampled patients (Patient 1). (Refer G488) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to patients assessed to receive home health services.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure one of seven sampled patients (Patient 1) had the right to be free from physical abuse by failing to: 1. Ensure Patient 1 was free from physical abuse from Licensed Vocational Nurse 1 (LVN 1). As a result, on 10/4/2023, Patient 1 sustained a left femur fracture (broken thigh bone) and was moaning (sign of discomfort) when LVN1 moved Patient 1’s left leg. Patient 1’s Final Report from the General Acute Care Hospital (GACH)’s emergency department dated 10/5/2023 indicated Patient 1 was identified having a displaced fracture (bone breaks into two or more pieces and moves out of alignment) of the greater trochanter (located at the top of the thighbone [femur] and is the most prominent and widest part of the hip) of the left femur, and a long-leg cast (serves as protection for the affected areas and allows broken bones to be set in place as they heal up) was applied on Patient 1’s left leg. On 11/1/2023 at 1:31 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) and the Director of Patient Care Services (DPCS) related to the home health agency’s failure to ensure Patient 1 was free from physical abuse from LVN1. On 11/2/2023 at 3:02 p.m., the agency sent the IJ Removal Plan (the facility's plan of action to correct the deficient practices) by email, and the survey team notified the ADM and the DPCS the IJ Removal Plan was not accepted on 11/3/2023 at 9:59 a.m. On 11/3/2023 at 12:00 p.m., the agency sent a revised IJ Removal Plan, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 11/3/2023 at 12:15 p.m. On 11/3/2023, at 12:50 p.m., the agency sent a revised IJ Removal Plan, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 11/3/23 at 2:05 p.m. The IJ was not removed. On 11/3/23 at 4:35 p.m., the survey team completed the survey tasks, and exited with the IJ not removed. Findings: During a review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 9/4/2013, with a diagnoses including other reduction deformities of the brain (absence of part of brain), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), developmental disorder of scholastic skills (a condition characterized by a significant discrepancy between an individual's perceived level of intellect and their ability to acquire new language and other cognitive skills), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Patient 1's Plan of Care (POC) dated for certification period from 9/12/2023 to 11/10/2023, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 33 to 42 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform observations of all physical systems and pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. During a review of the home security video with audio provided to the Department by Family Member 1 (FAM 1), dated10/4/2023, and timed at 10a.m., the video showed LVN 1 (identified by FAM1) put a shirt on Patient 1 while Patient 1 was laying on a table. The video showed LVN 1 tossed and rolled Patient 1 in a rough manner and at one point pulled at Patient 1’s left leg and Patient 1 was moaning. During a review of Patient 1’s GACH Final Report, dated 10/4/2023, the GACH Final Report indicated while in the Emergency Department (ED), FAM 1 received home security video that FAM2 sent her. The Final Report indicated the video was from 10/4/2023 around 10 a.m. and it showed the nurse (unidentified) rolling around the patient and at one point the nurse pulled at Patient 1’s left leg. The Final Report indicated Patient 1 had a displaced was applied. During an interview on 10/31/2023, at 12:50 p.m., with the ADM, the ADM stated the agency received a call on 10/5/2023, at 7:42 a.m., from FAM 1 who reported she (FAM1) took Patient 1 to the GACH on 10/4/2023. The ADM stated FAM1 stated Patient 1’s x-ray (a test that produces images of the structures inside the body such as the bones) showed Patient 1 had a fracture of the left femur. ADM stated FAM 1 also informed the agency that a home security camera captured LVN 1 being rough with Patient 1 while caring for Patient 1 on 10/4/2023. ADM stated the alleged physical abuse was reported to Child Family Services on 10/5/2023 and to the Department on 10/6/2023. ADM stated LVN 1 was placed on administrative leave on 10/5/2023. ADM 1 stated the local police department arrested LVN1 on 10/10/2023. During a telephone interview on 10/31/2023, at 1:16 p.m., with the DPCS, the DPCS stated the agency did not have a completed investigation report regarding the alleged physical abuse regarding LVN1 and Patient 1. The DPCS stated “It’s not finalized, we have to call and ask from our legal team.” During a concurrent interview and record review, on 10/31/2023, at 1:24 p.m., with the Registered Nurse Clinical Supervisor (RN 1), RN 1 stated the agency was unable to provide evidence the agency conducted abuse prevention training for LVN 1 and for the HHA’s staff (in general). During a concurrent interview and record review, on 10/31/2023, at 1:30 p.m., with the ADM, the ADM stated the agency’s grievance or complaint report was online, but the abuse allegation case for Patient 1 was not logged. ADM stated since family contacted the agency and reported this case, ADM stated it should have been logged in their grievance report online. During a telephone interview on 11/1/2023, at 9:02 a.m., with FAM1, FAM 1 stated on 10/4/2023, she received a call from LVN 1 around 11 a.m., that Patient 1 was sweating and in pain (unidentified level) every time LVN 1 moved Patient 1’s left leg. FAM 1 stated when she came home around 4 p.m., on 10/4/2023, she noticed Patient 1 was in pain when she touched his left thigh. FAM 1 stated she also noticed Patient 1 was sweaty and extremely uncomfortable, so she took him to the GACH’s emergency room (ER) where Patient 1 had an x-ray procedure done that indicated Patient 1’s left femur was fractured. FAM 1 stated the ER doctor (unidentified) informed her that the kind of injury Patient 1 sustained could be associated with abuse. FAM 1 stated FAM1 and FAM2 immediately reviewed their home security camera video, dated 10/4/2023 at around 10 a.m., that showed LVN 1 rolling Patient 1 around in a table in a very rough manner. FAM 1 stated the local Police Department came, saw, and gathered the home security video and informed her that Patient 1’s femur fracture could have resulted from the way LVN 1 handled him in a very rough manner on 10/4/2023. FAM 1 stated Patient 1 never had any previous fractures or injuries. During an interview on 11/1/2023, at 12:25 p.m., with the DPCS, the DPCS stated she reported the abuse allegation to the Department on 10/6/2023, at 2:30 p.m., or more than 24 hours after FAM 1 reported the abuse allegation to the agency. The DPCS stated the abuse allegation should have been reported to the Department within 24 hours in accordance with the regulations. During a review of the agency’s policy and procedure titled, “Abuse, Neglect, or Exploitation,” with a revised date of 7/14/2023, indicated employees who identify, notice, suspect or recognized incidences or circumstances of mistreatment, verbal, mental, sexual and/or physical abuse, including injuries of unknown source, neglect, misappropriation of personal patient property, or exploitation of patient/clients and/or family/caregivers or employees must report these observations/concerns immediately to the agency and other appropriate authorities in compliance with applicable laws and regulations. Alleged incidences or circumstances will be reported first to the Legal Department and then to enforcement agencies according to applicable laws and regulations. All incidences or circumstances will be thoroughly investigated, and the results of internal investigations will be reported to appropriate enforcement agencies within five (5) working days or as prescribed by state law. Each employee will receive training regarding possible signs and/or symptoms of abuse, neglect and exploitation and be oriented and be familiar with the process of reporting and investigating suspected incidents of abuse, neglect, or exploitation of patient/clients and/or family/caregiver. During a review of the agency’s policy and procedure titled, “Grievances and Complaints”, revised 7/14/2023, indicated at the time of admission, and as needed, patient/client and/or family/caregiver shall be informed of their rights to voice grievances regarding treatment or care, lack of respect of property, or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal. Grievances received from a patient/client and/or family/caregiver will be promptly reported to Office Leadership/Designee for assessment determination.

Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to conduct an complaint investigation regarding mistreatment and physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) by a Licensed Vocational Nurse 1 while doing patient care for one out of 7 sampled patients (Patient 1). This deficient practice placed the patient at risk for further harm and for more potential abuse. On 10/31/23, at 11 a.m., a complaint validation survey was conducted at the home health agency (HHA) regarding an allegation that LVN 1 physically abused Patient 1, who sustained a left femur (thigh bone) fracture (a partial or complete break in the bone) while under her care. A review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 9/4/2013, with a diagnoses including other reduction deformities of the brain (absence of part of brain), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), developmental disorder of scholastic skills (a condition characterized by a significant discrepancy between an individual's perceived level of intellect and their ability to acquire new language and other cognitive skills), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period 9/12/2023 to 11/10/2023, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 33 to 42 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform observations of all physical systems and pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. During an interview on 10/31/2023, at 12:50 p.m., with the Administrator (ADM), the ADM stated the agency received a call on 10/5/2023, at 7:42 a.m., from a family member (FAM 1), who reported FAM 1 took Patient 1 to the general acute care hospital (GACH) on 10/4/2023 due to left leg pain when touched and Patient 1 was sweating. Patient 1 had an Xray done (a test that produces images of the structures inside the body such as the bones) and showed Patient 1 had a fracture on the left femur. The ADM also stated FAM 1 also informed the agency that a home security camera captured LVN 1 being rough while caring for Patient 1 on 10/4/2023. During a telephone interview on 10/31/2023, at 1:16 p.m., with the Director of Patient Care Services (DPCS), the DPCS was asked for a copy of the abuse investigation report. The DPCS stated she could not give a copy at this time because the investigation report had not been finalized by the agency’s legal team. During a review of the agency’s policy and procedure titled, “Abuse, Neglect, or Exploitation,” with a revised date of 7/14/2023, indicated all alleged abuse incidences or circumstances will be thoroughly investigated, and the results of internal investigations will be reported to appropriate enforcement agencies within five (5) working days or as prescribed by state law.

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 alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) in their grievance log and its resolution for one out of 7 sampled patients (Patient 1). This deficient practice placed Patient 1 and other patients at risk that grievances presented to the HHA will not be addressed and resolved. On 10/31/23, at 11 a.m., a complaint validation survey was conducted at the home health agency (HHA) regarding an allegation that LVN 1 physically abused Patient 1, who sustained a left femur (thigh bone) fracture (a partial or complete break in the bone) while under her care. A review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 9/4/2013, with a diagnoses including other reduction deformities of the brain (absence of part of brain), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), developmental disorder of scholastic skills (a condition characterized by a significant discrepancy between an individual's perceived level of intellect and their ability to acquire new language and other cognitive skills), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period 9/12/2023 to 11/10/2023, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 33 to 42 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform observations of all physical systems and pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. During an interview on 10/31/2023, at 12:50 p.m., with the Administrator (ADM), the ADM stated the agency received a call on 10/5/2023, at 7:42 a.m., from a family member (FAM 1), who reported FAM 1 took Patient 1 to the general acute care hospital (GACH) on 10/4/2023 due to left leg pain when touched and Patient 1 was sweating. Patient 1had an Xray done (a test that produces images of the structures inside the body such as the bones) and showed Patient 1 had a fracture on the left femur. The ADM also stated FAM 1 also informed the agency that a home security camera captured LVN 1 being rough while caring for Patient 1 on 10/4/2023. The ADM further stated that FAM 1 filed a grievance, but the agency failed to document the complaint in their grievance book in order to find a resolution to the issue as per their agency’s policy. During a review of the agency’s policy and procedure titled, “Grievances and Complaints”, revised 7/14/2023, indicated at the time of admission, and as needed, patient/client and/or family/caregiver shall be informed of their rights to voice grievances regarding treatment or care, lack of respect of property, or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal. Grievances received from a patient/client and/or family/caregiver will be promptly reported to Office Leadership/Designee for assessment determination.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to report an alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) to the Department of Public Health Licensing and Certification unit within 24 hours as per agency’s policy for one out of seven sampled patients (Patient 1). This failure resulted in the delay of investigation by the Department of Public Health, and had the potential for the abuse to continue, and cause resident’s further physical and psychosocial harm On 10/31/23, at 11 a.m., a complaint validation survey was conducted at the home health agency regarding an allegation that Licensed Vocational Nurse (LVN) 1 physically abused Patient 1, who sustained a left femur (thigh bone) fracture (partial or complete break in the bone) while under her care. A review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 9/4/2013, with a diagnoses including other reduction deformities of the brain (absence of part of brain), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), developmental disorder of scholastic skills (a condition characterized by a significant discrepancy between an individual's perceived level of intellect and their ability to acquire new language and other cognitive skills), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period 9/12/2023 to 11/10/2023, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 33 to 42 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform observations of all physical systems and pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. During an interview on 10/31/2023, at 12:50 p.m., with the Administrator (ADM), the ADM stated the agency received a call on 10/5/2023, at 7:42 a.m., from family member (FAM 1), who reported FAM1 took Patient 1 to the general acute care hospital (GACH) on 10/4/2023 due to left leg pain when touched and Patient 1 was sweating. Patient 1 had an x-ray done (a test that produces images of the structures inside the body such as the bones) showed Patient 1 had a fracture of the left femur. The ADM also stated FAM 1 also informed the agency that a home security camera captured LVN 1 being rough with Patient 1 while caring for Patient 1 on 10/4/2023. During an interview on 11/1/2023, at 12:25 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she reported the abuse allegation to the Department on 10/6/2023, at 2:30 p.m., whicjhwas more than 24 hours after FAM 1 reported the abuse allegation to the agency. The DPCS stated the abuse allegation should have been reported to the Department within 24 hours in accordance with the regulations. During a review of the agency’s policy and procedure titled, “Abuse, Neglect, or Exploitation,” with a revised date of 7/14/2023, indicated all alleged abuse incidences or circumstances will be reported to appropriate enforcement agencies within 24 hours.

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 failed to update the medication profile (the lists of medication a patient is taking and had used) to reflect the patient's current medications for one of seven sampled patients (Patient 4). This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. A review of Patient 4's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) indicated a start of care date (SOC) of 10/20/23, with diagnosis that included congenital malformation of the brain (group of brain defects or disorders that develop in the womb and are present at birth). During a review of Patient 4's Plan of Care for certification period from 10/20/23 to 12/18/23, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 80 to 100 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform observations of all physical systems and pain each shift and for assessment of all body system and medication compliance. During a a home visit conducted on 11/3/2023 at 10 a.m., at Patient 4's residence with LVN 3. Patient 4 was observed lying in bed with both lower extremities contracted. During an observation and a review of Patient 4's medications on 11/3/2023, at 10:30 a.m., a bottle of Nasonex (medication to aid with breathing) 50 micrograms (mcg, a unit of measurement) give two sprays one time daily was observed. During an interview with family member (FM), she stated the Nasonex medication had been discontinued and Patient 4 was not taking it for a month. During an interview on 11/3/2023, at 11 a.m., with LVN 3, she stated she forgot to coordinate the discontinued Nasonex medication with the agency. During an interview on 11/3/2023, at 1 p.m., with the Director of Patient Care Services Director (DPCSD), the DPCS stated, in general, the agency’s visiting nurse had to check the patient's medications on every visit for changes and update the patient's medication profile to reflect the changes. A review of the agency's undated policy and procedure titled, "Administration of Medication, indicated, when there is a discrepancy in the medications, the nurse will contact the physician by telephone as soon as possible to verify the medication regimen. The nurse will instruct the patient and family in the correct medication regimen. The nurse will document all telephone conversations and instructions given to the patient and/or family in the patient clinical record.

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 home health agency failed to ensure the physician’s treatment order to cleanse the gastric tube (a tube surgically inserted into the stomach for medications and nutrition administration) were followed for three of 7 sampled patients (Patient 1, Patient 2, and Patient 6). This deficient practice had the potential to result in a gastric tube site infection and other possible wound complications when the site is not observed, monitored, and treatment orders are not implemented as ordered. During a review of Patient 6's admission record indicated a start of care (SOC) date of 9/10/23, with a terminal diagnosis of anoxic brain damage (characterized by brain damage from lack of oxygen to the brain). During a review of Patient 6's Plan of Care (POC) dated for certification period from 9/10/2023 to 11/8/2023, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 112 to 140 hours of skilled nursing (SN) per month for 60 days and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to provide wound care at Stage 4 sacral-coccyx pressure ulcer as follows: cleanse with sterile wound cleanser, pat dry, apply Silvadene cream directly to wound bed, fill loosely with filler Collagen dry foam, dress with Calcium Alginate, cover with silicone bordered foam dressing and secure with tape daily and as needed when soiled. During a review of Patient 6's Skilled Nursing Notes dated 9/11/23 to 10/31/23, did not indicate a documented evidence that a wound care was provided as ordered to Patient 6. During an interview on 11/3/23 at 1 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse should have specified in their documentation notes each wound care treatment provided as ordered. Findings: a. During a review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 9/4/2013, with a diagnoses including other reduction deformities of the brain (absence of part of brain), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), developmental disorder of scholastic skills (a condition characterized by a significant discrepancy between an individual's perceived level of intellect and their ability to acquire new language and other cognitive skills), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a "G-tube", through the abdomen and into the stomach). During a review of Patient 1's Plan of Care (POC) dated for certification period from 9/12/2023 to 11/10/2023, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 33 to 42 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform observations of all physical systems and pain each shift and as needed, to report all adverse (bad) changes to the physician/RN supervisor/Caregiver, and to perform G-tube site care with warm soapy water with clean technique daily and as needed to remove exudates (fluid that leaks out of blood vessels into nearby tissues). During a review of Patient 1's Skilled Nursing Notes from dates 10/2/2023 to 10/4/2023, the Skilled Nursing Notes indicated no documented evidence that the skilled nurse provided G-tube site care as ordered. b. During a review of Patient 2's Face Sheet, the Face Sheet indicated the agency admitted Patient 2 on 8/23/2012, with a diagnosis including other disorders of lung, congenital malformation syndrome (structural or functional anomalies that occurs at or before birth), and encounter for attention to gastrostomy. During a review of Patient 2's Plan of Care (POC) dated for certification period from 10/25/2023 to 12/23/2023, the POC indicated an order for the LVN to provide 52 to 65 hours of skilled nursing (SN) per week and for the RN to visit at least once every 60 days and two visits as needed for supervision and case management. The POC indicated for the SN to perform observations of all physical systems every shift and as needed, report all adverse changes to the physician/RN supervisor/caregiver, and to perform G-tube site care with warm soapy water rinse with clear/clean water, pat dry with clean technique every shift and as needed to remove exudates. During a home visit conducted on 11/2/2023, at 3:35 p.m., at Patient 2's residence with the License Vocational Nurse 4 (LVN 4), Patient 2 was observed laying on a mat with a G-tube attached to his abdomen. During a review of Patient 2's Skilled Nursing Notes from dates 10/23/2023 to 10/27/2023, the Skilled Nursing Notes indicated no documented evidence that the skilled nurse provided G-tube site care as ordered. During an interview with the Clinical Manager (DPCS) on 11/3/2023 at 12:25 p.m., the DPCS stated the agency SN should document every treatment they provide to the patient in their nursing notes as ordered by the physician. A review of the agency’s policy and procedure titled, “Home Health Certification and Plan of Care”, revised 7/14/2023, indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to all treatments, procedures, medications, and services authorized to be provided by direct care staff. A written plan of care will be initiated on the start of care date and updated at least within the last five days of the current certification or as patient’s condition warrants.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to ensure caregiver training, instructions or health teaching was provided to the caregiver on how to administer gastric tube (GT, a tube surgically inserted into the stomach to administer nutrition and medications) feeding for one out of seven patients, (Patient 4). This deficient practice had the potential to result in complications when family members are not trained to administer GT feedings safely and could jeopardize the patient 's health and wellbeing. A review of Patient 4's Plan of Care (POC) indicated a start of care date (SOC) of 10/20/23, with diagnosis of congenital malformation of the brain (group of brain defects or disorders that develop in the womb and are present at birth). During a review of Patient 4's POC for certification period 10/20/23 to 12/18/23, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 80 to 100 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to provide enteral feeding, daytime feedings - Jevity 1.0 calorie (cal) 500 milliliters (ml) at 50 ml/hour (hr) rate via enteral pump from 8 a.m. to 6 p.m.; nighttime feeding - Jevity 1.0 cal 500 ml at 50 ml/hr rate via enteral pump (a feeding machine) from 8 p.m. to 6 a.m. During a home visit observation conducted on 11/3/23, at 10 a.m. at Patient 4's residence with LVN 3, Patient 4 was observed lying in bed with both lower extremities contracted. A bottle of Jevity 1.0 500 ml bottle was observed hanged and was infusing (feeding) at 50 ml/hr connected to Patient 4’s G. On 11/3/23, at 10:45 a.m., during an interview with FM 1, she stated she gives the GT feeding at night when the nurses leave from their shift. During a record review of Patient 4's Skilled Nurse Notes from dates 10/20/23 through 10/31/23, indicated no documented evidence of a patient/caregiver training on how to administer GT feeding with a return demonstration from the family member to validate if the family has the skills and knowledge in following the correct GT feeding administration procedures. During an interview on 11/3/2023, at 2 p.m., the Director of Patient Care Services (DPCS) stated the visiting nurse should have taught FM1 the proper GT feeding procedures and had FM 1 return demonstrate to the visiting nurse the administration of GT feedings to validate the proper way of GT feeding administration. A review of the agency's undated policy, titled, "Patient Education", indicated the agency should educate patients about their disease process, care plan and treatments while on service.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities] regarding Organization and Administration of Services was met as follows: The HHA’s Administrator, who is responsible for the day-to-day operation of the home health agency, for one of seven patients, Patient 1, failed to ensure the allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) by a Licensed Vocational Nurse (LVN 1), was handled and investigated timely, reported to the Department of Public Health Licensing and Certification unit within 24 hours, and abuse trainings were provided to the home health agency staffs. (Refer to G948). 2. The HHA failed to implement its policy and procedure on Abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being), Neglect (refusal or failure of a caregiver to provide for the needs of a vulnerable adult), or Exploitation (taking improper advantage of an individual which could involve finances, material, labor, or activity) and provide abuse in-service trainings to the HHA staffs. (Refer to G984) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to patients assessed to receive home health services.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency’s Administrator, who is responsible for the day-to-day operation of the home health agency, for one of seven patients, Patient 1, failed to ensure the allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) by a Licensed Vocational Nurse, was handled and investigated timely, reported to the Department of Public Health Licensing and Certification unit within 24 hours, and abuse trainings were provided to the home health agency staffs. This failure resulted in the delay of abuse investigation by the Department of Public Health, and had the potential for the abuse to continue, and cause resident’s further physical and psychosocial harm. On 10/31/2023, at 11 a.m., a complaint validation survey was conducted at the home health agency (HHA) regarding an allegation that Licensed Vocational Nurse (LVN) 1 physically abused (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) Patient 1, who sustained (suffer) a left femur (thigh bone) fracture (a partial or complete break in the bone) while under her care. During a review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the home health agency admitted Patient 1 on 9/4/2013, with diagnosis that included other reduction deformities of the brain (absence of part of brain), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), developmental disorder of scholastic skills (a condition characterized by a significant discrepancy between an individual's perceived level of intellect and their ability to acquire new language and other cognitive skills), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period 9/12/2023 to 11/10/2023, the POC indicated an order for the LVN to provide 33 to 42 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform physical observations and observe for pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. During an interview on 10/31/2023, at 12:50 p.m., with the Administrator (ADM), the ADM was asked about her job description. The ADM stated as an Administrator, she is responsible for the day-to-day operation (function) of the HHA. The ADM was asked if abuse prevention training were provided to LVN 1 and other staffs, the ADM stated the agency should have provided abuse prevention training yearly to all staff, however, the ADM was unable to provide evidence of abuse training conducted for LVN 1 and for the all the other HHA staffs. When the ADM was asked if there was an abuse investigation report done by the agency for Patient 1, the ADM stated, none at this time. When ADM was asked if Patient 1’s family member’s grievance regarding the alleged abuse by LVN 1 was filed, she stated no. When ADM was asked if the HHA reported alleged abuse to the Department in appropriate time frame, she stated no. A review of the HHA’s “Operation Manager Job Description”, indicated, that one may serve in the capacity of office administrator, appointed by and reporting to the governing body, and responsible for all day-to-day operations of the office. Those duties include to be responsible for ongoing compliance with all current federal, state, and local regulations, company policies and procedures, accrediting organization standards, and reimbursement guidelines, oversees the handling of patient and employee complaints and is responsible for timely responses to grievances, Responsible for completion of all required reports and corrective action plans, and adheres to and promotes agency’s policies and procedures.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to: 1. Implement its policy and procedure on Abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being), Neglect (refusal or failure of a caregiver to provide for the needs of a vulnerable adult), or Exploitation (taking improper advantage of an individual. It could involve finances, material, labor, or activity). 2. Provide abuse in-service trainings to the HHA staffs. This deficient practice placed all the patients at risk for potential abuse by the home health agency staffs. On 10/31/2023, at 11 a.m., a complaint validation survey was conducted at the home health agency (HHA) regarding an allegation that Licensed Vocational Nurse 9 (LVN) physically abused (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being) Patient 1, who had sustained (suffer) a left femur (thigh bone) fracture (partial or complete break in the bone) while under her care. A review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 9/4/2013, with a diagnoses including other reduction deformities of the brain (absence of part of brain), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), developmental disorder of scholastic skills (a condition characterized by a significant discrepancy between an individual's perceived level of intellect and their ability to acquire new language and other cognitive skills), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for the certification period 9/12/2023 to 11/10/2023, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 33 to 42 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once every 60 days and two visits as needed for supervision, case management and recertification every 60 days. The POC indicated for the SN to perform observations of all physical systems and pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. During an interview on 10/31/2023, at 12:50 p.m., with the Administrator (ADM), the ADM was asked if abuse prevention trainings were provided to LVN 1 and the rest of their HHA staff, the ADM stated the agency should provide abuse prevention training every year to all staff but the ADM was unable to provide evidence that abuse trainings were provided to LVN 1 and to the rest of the home health agency staffs. During an interview on 11/2/2023 at 1 p.m. with LVN 2, LVN 2 was asked if the agency had provided abuse training, LVN 2 stated she had sexual harassment training last year. During an interview on 11/3/2023 at 10:30 a.m. with LVN 3, LVN 3 stated she remembered having just one abuse training ever since she was hired. During a review of the agency’s policy and procedure titled, “Abuse, Neglect, or Exploitation,” with a revised date of 7/14/2023, indicated each employee will receive training regarding possible signs and/or symptoms of abuse, neglect and exploitation and be oriented and be familiar with the process of reporting and investigating suspected incidents of abuse, neglect, or exploitation of patient/clients and/or family/caregiver.