Every finding on record at Maxim Healthcare Services Inc

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Partial Extended Recertification surveys. Representing the California Department of Public Health: Surveyors 39796, HFEN and 39210, HFEN. The survey team entered the Home Health Agency on 11/7/23 at 0900 hours. Glossary of Abbreviations: P&P: Policy and Procedure RN: Registered Nurse

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their emergency P&P and plan included a process for cooperation and collaboration with tthe regional emergency preparedness officials. This created the risk of not maintaining an integrated response during a disaster or emergency situation. Findings: Review of the agency's P&P on emergency preparedness was conducted on 11/15/23. The agency's P&P titled Emergency Preparedness Program revised 10/6/23, showed in the event of an evacuation, community resources might include the American Red Cross, community utility, and emergency service agencies of the clients who are high risk due to the use of life support system. However, the agency's emergency preparedness P&P and plan failed to describe the agency's process in engaging and coordinating with the regional emergency preparedness officials. On 11/17/23 at 1345 hours, an interview and concurrent agency document review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P and plan included procedures to inform the state and local emergency officials about the patients in need of evacuation from their residences due to an emergency situation. This created the risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency's P&P on emergency preparedness program was conducted on 11/15/23. The Emergency Preparedness Program P&P revised 10/6/23, showed the office shall provide notification to community utility and emergency service agencies for the patients who are on the high risk category due to the use of life support system. However, the agency's emergency preparedness P&P and plan failed to describe when and how information would be communicated to the emergency officials in the event a patient needed evacuation at any time due to an emergency situation based on the patient's psychiatric condition and home environment. On 11/17/23 at 1345 hours, an interview and concurrent agency document review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan was reviewed and updated every two years to include the names and contact information of entities who provided services under agreement, patient's physician, and volunteers, creating the increased risk of not addressing the care needs for the patients during the emergency events. Findings: Review of the agency's emergency preparedness communication plan was conducted on 11/15/23. The emergency preparedness communication plan showed the names and contact information of the agency's staff. However, the agency's communication plan failed to show the names and contact information of entities who provided services under agreement, patients' physicians, and volunteers. On 11/17/23 at 1345 hours, an interview and concurrent agency document review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included the contact information of the federal, state, and tribal emergency preparedness staff and other sources of assistance. This failure had the potential to negatively impact the patients' care needs during the emergency events. Findings: Review of the agency's emergency preparedness P&P and plan was conducted on 11/15/23. The agency's emergency preparedness plan did not include the contact information of the federal, state, and tribal emergency preparedness staff and other sources of assistance. On 11/17/23 at 1345 hours, an interview and concurrent agency document review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included the information related to the alternate means of communicating with the staff, federal, state, regional and local emergency management agencies, creating the risk of not being able to communicate to meet the patients and staff needs during an emergency. Findings: Review of the agency's emergency preparedness P&P and plan was conducted on 11/15/23. The agency's Emergency Preparedness Program revised 10/6/23, showed the agency will develop and maintain the emergency preparedness communication plan including the primary and alternate means for communicating with the agency'staff, federal, state, tribal, regional, and local emergency management agencies. However, the agency's emergency preparedness P&P and plan did not include the information for the primary or alternate means in communicating with the regional, or local emergency management agencies. On 11/17/23 at 1345 hours, RN 1 was informed and acknowledged the finding.

The following reflects the findings of the California Department of Public Health during the concurrent Partial Extended Recertification and Emergency Preparedness surveys. Representing the California Department of Public Health: Surveyors 39796, HFEN and 39210, HFEN. The survey team entered the Home Health Agency on 10/24/23 at 0900 hours. The survey team conducted 3 home visits and reviewed 4 active and 2 closed clinical records. Glossary of Abbreviations and Brief Definitions: °F: degrees Fahrenheit AFO: ankle foot orthosis AROM: Active Range of Motion Curlin pump: a portable multi-therapy infusion pump G-tube: gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) H: hour hr: hour HHA: home health agency Hickman catheter: a central venous catheter most often used for the administration of chemotherapy or other medications, as well as for the withdrawal of blood IV: intravenous LVN: Licensed Vocational Nurse MAR: Medication Administration Record mcg: microgram(s) meq: milliequivalent mg: milligram(s) min: minute ml: milliliter(s) mmHg: millimeter of mercury OASIS: Outcome and Assessment Information Set Oxygen Saturation level: a term referring to the concentration of oxygen in the blood, the normal blood oxygen levels are considered 95 to 100 percent PCG: Patient Caregiver PICC line: Peripherally Inserted Central Catheter (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period) P&P: Policy and Procedure POC: Plan of Care PRN: As Needed PROM: Passive Range of Motion Q: Every QD: Daily RN: Registered Nurse SN: Skilled Nursing/Nurse Stage 1 Pressure injury: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin SOC: Start of Care TPN: Total Parenteral Nutrition (a method of feeding that bypasses the gastrointestinal tract) Unstageable Pressure injury: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessment was completed accurately and consistently with the patient's immediate needs for one of seven sampled patients (Patient 7). This failure created the risk of not identifying and addressing the care needs timely for this patient. Findings: Review of Patient 7's closed clinical record was initiated on 11/9/23. The clinical record showed the SOC was 12/15/21. The patient was certified for home health services during the certification periods from 6/13/22 to 8/11/22, and 8/12/22 to 10/10/22. The Start of Care OASIS dated 12/15/21, showed no documented evidence the patient’s sleep and wake hours were assessed. On 11/17/23 at 1115 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the finding.

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 HHA failed to ensure the medication profiles were updated to reflect the current medications three of seven sampled patients (Patients 3, 4, and 5). This failure created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. Findings: Review of the agency’s P&P titled Medication Profile revised 4/9/21, showed the patients receiving medications will have a current, accurate medication profile maintained in the medical record and home folder. Any deviations in taking medications as ordered will be documented in the medical record, and the ordering practitioner will be notified. 1. Review of Patient 5's clinical record was initiated on 11/9/23. The clinical record showed the SOC was 8/2/22. The patient was certified for home health services during the certification periods from 7/28/23 to 9/25/23, and 9/26/23 to 11/24/23. The medication profile, for the certification period from 9/26/23 to 11/24/23, showed the medications included glycerin (medication used for dry eyes) topical liquid one drop both eyes every six hours, Visine tears (medication used to relieve redness caused by minor irritation) one drop both eyes four times daily, mupirocin 2% (used to treat bacterial skin infection) topical as needed two times daily to affected areas, potassium (supplement) 20 mEq one time daily, sertraline (antidepressant) 50 mg three tablets via G-tube daily, and famotidine (antiulcer) 20 mg two times daily. On 11/8/23 at 1307 hours, a joint home visit was conducted with LVN 4 to Patient 5’s home. Review of the patient’s medications with LVN 4 showed the patient was no longer taking glycerin topical liquid one drop both eyes every six hours, Visine tears one drop both eyes four times daily, mupirocin 2% topical as needed two times daily to affected areas, and potassium 20 mEq one time daily. Further review of Patient 5's medications showed Patient 5 was on sertraline 20 mg/ml oral concentrate 7.5 ml daily instead of 50 mg three tablets daily, Refresh tears two drops to both eyes every four hours, and famotidine 40 mg one tablet every other day instead of 20 mg two time daily as per the medication profile. On 11/17/23 at 1458 hours, an interview and concurrent record review was conducted with RN 2. RN 2 was informed of the findings. 2. Review of Patient 3's clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/16/21. The patient was certified for home health services during the certification periods from 8/8/23 to 10/6/23, and 10/7/23 to 12/5/23. The medication profile for the certification period from 10/7/23 to 12/5/23, showed the medications including hydrocodone 5 mg - acetaminophen 325 mg (pain medication) one tablet every six hours as needed for pain. On 11/8/23 at 0901 hours, a joint home visit was conducted with RN 3 to Patient 3's home. Review of the patient's medications with RN 3 showed the patient was no longer taking hydrocodone 5 mg - acetaminophen 325 mg one tablet. On 11/17/23 at 1215 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledge the finding. 3. Review of Patient 4's clinical record was initiated on 11/8/23. The clinical record showed the SOC was 5/26/22. The patient was certified for home health services during the certification periods from 7/20/23 to 9/17/23, and 9/28/23 to 11/16/23. The Medication Profile, for the certification period from 9/28/23 to 11/16/23, showed the medications included the following: - Diastat AcuDial (rectal gel used to treat seizures) 5 mg - 7.5 mg 10 mg rectal kit QD PRN - bisacodyl (laxative) 10 mg rectal suppository one time a week PRN - fluticasone propionate (corticosteroid) 50 mcg nasal spray suspension QD PRN - ipratropium bromide (bronchodilator) 0.02 % solution for inhalation Q4H PRN On 11/8/23 at 0838 hours, a joint home visit was conducted with LVN 2 to Patient 4’s home. Review of the patient’s medications with the LVN 4 showed the Diastat AcuDial 5 mg - 7.5 mg 10 mg rectal kit had an expiration date of 2/2023 and the patient was no longer on bisacodyl 10 mg rectal suppository. The labels of the fluticasone propionate 50 mcg nasal spray suspension showed to administer at bedtime instead of QD PRN and the ipratropium bromide 0.02 % solution for inhalation showed to administer Q6H instead of Q4H PRN as per the medication profile. On 11/8/23 at 1045 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 was informed and acknowledged the findings. On 11/17/23 at 1340 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review and interview, the agency failed to ensure the updated comprehensive assessments were completed within the last five days of every 60 days for one of seven sampled patients (Patients 1), creating the risk of not addressing the care needs for these patients. Findings: The agency's P&P titled Re-Assessments/Recertification revised 7/14/23, showed a qualified clinician is assigned to complete comprehensive recertification assessment within the last five days of the current 60-day certification period. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 3/28/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23, and 9/19/23 to 11/17/23. Review of the Recertification OASIS dated 9/15/23, showed the RN had checked Patient 1's vital signs which included the heart rate, respiratory rate, oxygen saturation level, and temperature. However, the RN failed to assess the patient's blood pressure as part of the comprehensive assessment. On 11/17/23 at 1223 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

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 agency failed to ensure the comprehensive assessment was completed within the 48 hours of the patient return to home from a hospital admission of 24 hours for one of seven sampled patients (Patient 6), creating the risk of not addressing the care needs for this patient. Findings: The agency's P&P titled Reassessments/Recertification revised 7/14/23, showed a follow-up comprehensive assessment must be completed within 48 hours of a patient's discharge from the hospital or within 48 hours of the agency knowledge of the hospital discharge or on the date as ordered by the physician. The assessment is referred to as a resumption of care. Review of Patient 6's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 2/24/23. The patient was certified for home health services during the certification period from 6/19/23 to 8/17/23. Review of the SN note dated 7/18/23, showed the patient was admitted to the hospital. Review of the SN communication note dated 7/18/23, showed the patient had a change of condition and was brought to the hospital and subsequently admitted. Further review of the communication note dated 7/19/23, showed the patient was discharged from the hospital on 7/20/23. However, there was no documented evidence a comprehensive assessment was completed within 48 hours of the patient's return to the home. On 11/17/23 at 1100 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked if the resumption of care assessment was completed. RN 1 replied she did not see any assessment. RN 1 was also asked about the timeline to complete the resumption of care assessment. RN 1 replied within 48 hours of the patient's return from a hospital discharge. RN 1 was informed and acknowledged the finding.

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 agency failed to ensure four of seven sampled patients (Patients 1, 4, 5, and 6) were provided with care and services as per the written POCs, creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: The agency's P&P titled Patient/ Client Scheduling revised 7/14/23, showed to ensure the patient/client shifts are scheduled and completed according to the plan of care/plan of service. If at any time the services provided do not match the ordering practitioner order (or range of orders) as required by the plan of care, a missed shift/visit note and notification to the ordering practitioner is required. The clinical record will include all documentation related to the missed shift including alternative care for the patient. 1. Review of Patient 6's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 2/24/23. The patient was certified for home health services during the certification period from 6/19/23 to 8/17/23. The POC, for the certification period from 6/19/23 to 8/17/23, cited SN visits 134 to 168 hours for 60 days, RN Supervisory visit one time every 60 days and PRN for resumption of care, change in condition or care coordination. The POC also showed to apply AFO braces on bilateral lower extremities, apply splints on bilateral hands at night as tolerated at night, and apply long leg braces to bilateral legs as per patient tolerance and discretions, perform circulation check every two hours while in place. The POC cited SN to perform PROM and AROM to bilateral upper and lower extremities only to resistance and as tolerated by patients. However, review of the SN notes showed the following: * The SN notes showed the SN conducted the SN visits 131 hours and 46 minutes a week during Week 8 (8/6/23to 8/12/23), instead of 134 hours a week as ordered. * Review of the SN notes for the night shifts showed on 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/27, 6/28, 6/29, 6/30, 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, 7/7,7/8, 7/9, 7/10, 7/30, 7/31, 8/1,8/3, 8/4, and 8/8/23, the SN had performed the musculoskeletal assessment. The assessment showed the patient had rigidity and weakness on bilateral upper and lower extremities. However, further review of the SN notes for the night shift failed to show documented evidence the AFOs for the bilateral lower extremities, splints for the bilateral hands, and long leg braces for the bilateral lower extremities were applied as per the POC. In addition, the documentation showed capillary refill for the bilateral upper and lower extremities were checked. However, there was no documented evidence on the frequency of the circulation check. Further review of the SN notes dated 7/3,7/4,7/5,7/6,7/7 and 7/8/23, showed no documented evidence the SN had performed PROM and AROM to bilateral upper and lower extremities as ordered. On 11/17/23 at 1100 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was asked if the bilateral AFOs and braces were applied to the patient. RN 1 replied sometimes the patient refused. RN 1 was further asked if the patient’s refusal were documented. RN 1 replied no. RN 1 was further asked if the POC was followed. RN 1 replied no. RN 1 was informed and acknowledged the findings. 2. Review of Patient 4's clinical record was initiated on 11/8/23. The clinical record showed the SOC was 5/26/22. The patient was certified for home health services during the certification periods from 7/20/23 to 9/17/23, and 9/18/23 to 11/16/23. a. The POC, for the certification period from 7/20/23 to 9/17/23, cited SN visits 90 to 112 hours per week for head to toe and pain assessment each visit and as needed for changes in the patient condition; and report all adverse changes to the physician/ RN Supervisor/caregiver. The POC included SN to flush G-tube with 60 ml of water after feedings and give 160 ml of water daily as needed to maintain hydration bolus via G-tube. * Review of the SN notes showed the SN visits were not conducted as cited in the POC for the following weeks: - For Week 1 (7/20/23 to 7/22/23), no SN visit was conducted. - For Week 2 (7/23/23 to 7/29/23), 40 hours and 45 minutes of SN visits were conducted. - For Week 6 (8/20/23 to 8/26/23), 44 hours and 38 minutes of SN visits were conducted. - For Week 7 (8/27/23 to 9/2/23), 44 hours and 37 minutes of SN visits were conducted. - For Week 8 (9/3/23 to 9/9/23), 43 hours and 50 minutes of SN visits were conducted. - For Week 9 (9/10/23 to 9/16/23), 44 hours and 56 minutes of SN visits were conducted. * Review of the SN notes dated 8/31, 9/6, 9/7, 9/13 and 9/14/23, showed the SN had flushed the G- tube with 80 ml of water after each feeding instead of 60 ml as ordered. * Further review of the SN notes failed to show documented evidenced the SN had provided the 160 ml of water daily as needed to maintain hydration as ordered. b. The POC, for the certification period from 9/18/23 to 11/16/23, cited SN visits 90 to 112 hours per week for head to toe and pain assessment each visit and as needed for changes in patient condition; and report all adverse changes to the physician/RN Supervisor/Caregiver. The POC cited SN to flush GT with 60 ml of water after feedings and an additional 20 ml of water after feedings for additional hydration while using Pediasure formula. The POC also cited SN to give 160 ml of water daily as needed to maintain hydration bolus via G-tube. Review of the SN notes for the following showed the SN visits were not conducted as cited in the POC for the following weeks: - For Week 1 (9/18/23 to 9/23/23), 44 hours and 43 minutes of SN visits were conducted. - For Week 2 (9/24/23 to 9/30/23), 44 hours and 47 minutes of SN visits were conducted. - For Week 3 (10/1/23 to 10/7/23), 47 hours and 13 minutes of SN visits were conducted. - For Week 6 (10/22/23 to 10/28/23), 42 hours and 27 minutes of SN visits were conducted. - For Week 7 (10/29/23 to 11/4/23), 40 hours of SN visits were conducted. - For Week 8 (11/5/23 to 11/11/23), 33 hours of SN visits were conducted. On 11/17/23 at 1318 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. On 11/17/23 at 1432 hours, a follow-up interview and concurrent clinical record review was conducted with the Operations Manager. The Operations Manager was informed and acknowledged the findings. * Review of the SN notes (an example date of 10/31, 11/1, 11/2, 11/6, 11/7 and 11/8/23) showed the SN had flushed the G-tube with 80 ml of water after each feedings. However, review of the clinical record failed to show documented evidenced the SN had flushed the G-tube of 160 ml of water daily PRN as ordered. * Review of the Recertification OASIS dated 9/13/23, showed the RN performed respiratory assessment. The respiratory assessment showed the patient breath sound was clear. Review of the SN notes dated 9/18, 9/19,9/20, 9/21, 10/9, 10/10, 10/11, 10/16, 10/17, 10/18, 10/19,10/23,10/24, 10/25, 10/26, 10/31, 11/6, 11/7 and 11/8/23, showed the patient was assessed to have rhonchi (low-pitch lung sounds that sound like a combination of snoring and wheezing). However, review of the clinical record failed to show documented evidence the physician was notified of the changes in the respiratory condition as cited in the POC. On 11/17/23 at 1318 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 3. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 3/28/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. a. The POC, for the certification period from 7/21/23 to 9/18/23, cited SN visits 16 to 24 hours per week for head to toe and pain assessment each visit and as needed for changes in patient condition; and report all adverse changes to the physician/RN Supervisor/caregiver. The POC also cited to flush the lumen of Hickman catheter with normal saline and heparin (anticoagulant) at least every 24 hours and PRN line access. The POC also cited to administer TPN 1632 ml (with a 100 ml overfill) over 12 hours at 136 ml/hr via the Hickman catheter using a Curlin pump. The POC also cited to provide pressure relief the patient by repositioning every two hours and PRN to prevent skin breakdown and for comfort. * Review of the Recertification OASIS dated 7/17/23, showed the RN performed respiratory assessment. The respiratory assessment showed the patient’s breath sounds were diminished on the right mid lobe and had crackles/rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) on bilateral upper and lower lobe. Patient 1 was on 4 to 5 liters per minute of oxygen via nasal cannula with an oxygen saturation level at 97%. Review of the SN notes dated 7/31, 8/3, 8/7, 8/10, 8/13, 8/14, 8/19, 8/21, 8/25, 8/27, 9/4, 9/10 and 9/11/23, showed the SN had performed respiratory assessment. The patient’s breath sounds were assessed to have rhonchi to the bilateral lungs. However, there was no documented evidence the physician was notified of the changes in condition. * Review of the SN notes showed no SN visits were conducted for Week 1 (7/21/23 to 7/22/23) as ordered in the POC. * Review of the Medication Administration Record for the certification period from 7/21/23 to 9/18/23, showed to flush with heparin lock flush (porcine) 100 units/ml IV syringe 300 units (3 ml syringe) PRN 10 times daily which was inconsistent with the POC which showed heparin flush every 24 hours. Review of the MAR showed the SN had flush the Hickman catheter on 7/27, 7/31, 8/3, 8/7, 8/13, 8/14, 9/4, 9/10, and 9/11/23; however, the SN did not flush every 24 hours as cited in the POC. * Review of the SN notes dated 7/27, 7/31, 8/3, 8/7, 8/10, 8/13, 8/24, 8/19, 8/21, 8/25, 8/27, 8/28, 9/3, 9/4, 9/10 and 9/11/23, showed the SN had provided TPN at a rate of 141 ml/hr, instead 136 ml/hr as ordered. * Review of the SN notes dated 7/27, 7/31,8/3, 8/10, 8/13, 8/14, 8/19, 8/21, 8/25, 8/27, 8/28, 9/4, 9/10, and 9/11/23, showed on the section of the musculoskeletal intervention, the SN documented repositioning. However, the documentation failed to show as to which side of the patient was repositioned to. In addition, review of the SN notes dated 8/7/23, showed the SN documented the patient was repositioned to the left side at 1500 and 1700 hours. On 11/17/23 at 1304 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. b. The POC, for the certification period from 9/19/23 to 11/17/23, cited SN visits 16 to 24 hours per week for head to toe and pain assessment each visit and as needed for changes in patient condition; and report all adverse changes to the physician/RN Supervisor/caregiver. The POC cited to flush lumen of Hickman catheter with normal saline and heparin at least every 24 hours and PRN line access; to administer TPN 1632 ml (with a 100 ml overfill) over 12 hours at 136 ml/hr via Hickman catheter using a Curlin pump; and to provide pressure relief by repositioning the patient every two hours and PRN to prevent skin breakdown and for comfort. * The SN notes showed the SN conducted the SN visits for 7 hours and 52 minutes a week during Week 2 (9/24/23 to 9/20/23)), instead of 16 to 24 hours a week as ordered. * Review of the MAR for the certification period 7/21/23 to 9/18/23, showed to flush with heparin lock flush (porcine) 100 units/ml IV syringe 300 units (3 ml syringe) PRN 10 times daily which was inconsistent with the POC which cited to flush at least every 24 hours. Review of the MAR showed the SN had flush the Hickman catheter on 9/25, 10/1, 10/2, 10/8, 10/9, 10/16, 10/19, 10/23, 11/5, and 11/9/23, instead of at least every 24 hours as cited in the POC. * Review of the SN notes dated 9/25, 10/1,10/2, 10/8, 10/9, 10/16, 10/19, 10/23 and 10/30, 11/5, 11/6, 11/9 and 11/13/23, showed the SN had administered the TPN at a rate of 141 ml/hr, instead of 136 ml/hr as ordered in the POC. * Review of the Recertification OASIS dated 9/15/23, showed the RN performed respiratory assessment. The respiratory assessment showed the patient’s breath sounds was diminished on the right mid lobe and had crackles/rales on bilateral upper and lower lobe. Patient 1 was on 4 to 5 liters per minute of oxygen via nasal cannula with an oxygen saturation level at 97%. Review of the SN notes dated 10/8, 10/16, 10/19, 10/23, 10/30, 11/5 and 11/6 and 11/13/23, showed the SN had performed respiratory assessment. The patient’s breath sounds were assessed to have rhonchi to the bilateral lungs. However, there was no documented evidence the physician was notified of the changes in condition. * Review of the SN notes dated 10/8, 10/9, 10/16, 10/19, 10/23, 10/30, 11/5, 11/6, 11/9 and 11/13/23, showed the musculoskeletal intervention section was left blank. On 11/17/23 at 1304 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 4. Review of Patient 5's clinical record was initiated on 11/9/23. The clinical record showed the SOC was 8/2/22. The patient was certified for home health services during the certification periods from 7/28/23 to 9/25/23 and 9/26/23 to 11/24/23. * The POC, for the certification periods from 7/28/23 to 9/25/23 and 9/26/23 to 11/24/23, cited SN visits 90-112 hours a week for 60 days. In addition, the POC cited the following: - SN to provide skilled observation and assessment of vital signs, physical and mental/emotional status; - SN to complete a head to toe and pain assessment each shift and as needed for any changes in patient condition and to report adverse changes to the physician/RN supervisor/caregiver; - SN to notify the primary physician if vital signs are outside of the following parameters and unresolved by nursing intervention: temperature less than 97°F or greater than 100.4°F; heart rate less than 60 beats per minute or greater than 100 beats per minute (sustained over one hour or for signs of sepsis); respiratory rate less than 12 breaths per minute or greater than 18 breaths per minute (sustained over one hour or for signs of sepsis); systolic blood pressure less than 90 mmHg or greater than 120 mmHg (sustained over one hour or for signs of sepsis); diastolic blood pressure less than 60 mmHg or greater than 80 mmHg (sustained over one hour or for signs of sepsis); and oxygen saturations level below 92%; - Assess respiratory status every shift and for any changes in patient status; and - SN to provide wound care skin care and pressure injury prevention/ treatment orders: wound dressing changes daily and as needed for soiling to the left ischium (hip joint), buttock, sacrococcyx (area covering the sacrum and tailbone), and perineum (area between the anus and scrotum/vagina). Measure wounds at least weekly, if wound nurse is no longer measuring wound and providing wound care and notify the PCG/physician/RN supervisor of any changes. Assess skin status every shift for any changes in patient status. a. Review of the SN notes from 7/28/23 to 9/25/23 and 9/26/23 to 11/8/23, showed Patient 5 was noted with a change in condition to the heart rate, blood pressure, and lung sounds. For example: - The SN visit notes on 8/13 and 8/18/23, showed Patient 5's heart rate was greater than 100 beats per minute. - The SN visit notes on 8/23 and 8/24/23, showed Patient 5's blood pressure was noted at 84/59 mmHg and 88/65 mmHg. - The SN visit notes on 9/26 and 9/27/23, showed Patient 5's lung sounds were noted with "crackles", and "rales." However, there was no documented evidence nursing interventions had been implemented and improved the patient's heart rate, blood pressure, or respiratory status, or if the physician had been notified of the change in condition. b. Review of the SN notes from 7/28/23 to 9/25/23 and 9/26/23 to 11/8/23, showed Patient 5 was noted with wounds to the left ischial, perineum, and coccyx area. However, there was no documented evidence weekly measurements of the wounds were performed as per the POC. On 11/17/23 at 1428 hours, an interview was conducted with RN 1. RN 1 stated they had not been able to obtain the notes from the visiting wound care nurse. On 11/17/23 at 1330 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings. c. Review of the SN notes dated 9/1/23, showed Patient 5 had an IV to the right and left forearm; and swelling to the right forearm was noted. Review of the SN notes from 9/1 to 9/2/23, showed Patient 5 had an IV to the right and left wrist; and the right hand was elevated due to swelling. Review of the SN notes dated 9/2/23, showed Patient 5 had 2+ pitting edema (swelling caused by fluid accumulation in the tissues of the body with 3 to 4 millimeter depression and rebounding in 15 seconds or less) to both hands. Review of the SN note dated 9/3/23, showed Patient 5 was noted to have a PICC line on the right hand and was assessed to be mildly swollen with yellow/green marks and 2+ pitting edema to the right hand. Review of the SN note dated 9/4/23, showed Patient 5’s PICC line on the left hand had non pitting edema. However, further review of the clinical record failed to show documented evidence the physician or RN supervisor was notified of these assessments. On 11/17/23 at 1428 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the POC included individualized plan for the specific interventions, measurable outcomes and goals identified for two of seven sampled patients (Patients 4 and 6), creating the risk of not addressing the care needs for these patients. Findings: 1. Review of Patient 6's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 2/24/23. The patient was certified for home health services during the certification period from 6/19/23 to 8/317/23. The POC for the certification period from 6/19/23 to 8/317/23, cited the SN to assess the patient's identified problems: pain, weight, respiratory and musculoskeletal status. However, the SN failed to include measurable outcomes and goals for the identified problems. On 11/17/23 at 1100 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked if the POC needed to have measurable goals for the identified specific problems. RN 1 replied yes. RN 1 was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 11/8/23. The clinical record showed the SOC was 5/26/22. The patient was certified for home health services during the certification periods from 7/20/23 to 9/17/23, and 9/18/23 to 11/16/23. The POC, for the certification period from 9/18/23 to 11/16/23, showed the SN to flush G-tube with 60 ml of water after feedings and an additional 20 ml of water after feedings for additional hydration while using Pediasure formula. The POC also showed SN to give 160 ml of water daily as needed to maintain hydration bolus via G-tube. Review of the SN notes dated 10/31, 11/1, 11/2, 11/6, 11/7 and 11/8/23, showed the SN had flushed the G-tube of 80 ml of water after each feedings. However, review of the POC failed to show specific instructions as to when to flush 160 ml of water to maintain hydration. On 11/17/23 at 1318 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked as to when to give the 160 ml of water flush. RN 1 replied the instruction was not specific. RN 1 was informed and acknowledged the finding.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the SN provided treatment only as ordered by the physician for three of the seven sampled patients (Patients 2, 6, and 7), creating a risk for not providing consistent quality care to these patients. Findings: 1. Review of Patient 7's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 12/15/21. The patient was certified for home health services during the certification period from 6/13/22 to 8/11/22, and 8/12/22 to 10/10/22. The POC, for the certification period from 6/13/22 to 8/11/22, cited SN 32- 40 hours a week to apply AFO braces on lower extremities as tolerated while awake on wheelchair and report any redness, irritation, or skin breakdown to the physician or RN supervisor. * Review of the SN notes dated 6/13 to 7/5/22, and 7/21 to 7/22/22, and 8/3/22, showed the use of wrists splints. However, there was no documented evidence a physician had ordered the use of wrist splints. On 11/17/23 at 1115 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/28/21. The patient was certified for home health services during the certification period from 8/20/23 to 10/18/23, and 10/19/23 to 12/17/23. The POC, for certification period from 8/20/23 to 10/18/23, cited SN visits 134-168 hours per week. In addition, the POC cited Calmoseptine (moisture barrier) topical ointment one time daily to affected areas until resolved. Review of the SN visit noted dated 9/25/23, showed Moisture Barrier Paste was applied to both legs of the patient for dry skin instead of Calmoseptine. On 11/17/23 at 1102 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the finding. 3. Review of Patient 6's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 2/24/23. The patient was certified for home health services during the certification period from 6/19/23 to 8/317/23. The POC, for the certification period from 6/19/23 to 8/317/23, cited SN to apply AFO braces to bilateral lower extremities, splints to bilateral hands at night as tolerated, and long leg braces to the bilateral legs as per the patient's tolerance and discretions. * Review of the SN notes showed documentations of the use of wrists splints on 6/20, 6/21, 7/8, 7/11, 7/21, 7/24, 7/28, 8/3, and 8/7/23. * Review of the SN notes showed documentations of the use of mechanical lift on 7/5, 7/6, 7/7, 7/9, 7/10,7/16, 7/22, 7/25, 8/2, 8/4, and 8/5/23. However, there was no documented evidence the physician had ordered the use of wrist splints and mechanical lifts. On 11/17/23 at 1100 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked if there was a physician’s order for the use of wrists splint and mechanical lift. RN 1 replied there was no order. RN 1 was informed and acknowledged the findings.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the SN notified and coordinated with the physician the changes in condition for two of seven sampled patients (Patients 6 and 7), creating the risk of not addressing the care needs for these patients. Findings: 1. Review of Patient 6's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 2/24/23. The patient was certified for home health services during the certification period from 6/19/23 to 8/17/23. The POC, for the certification period from 6/19/23 to 8/17/23, cited SN to assess integumentary ever shift and as needed for change in the patient's status. Review of the SN notes dated 8/2, 8/3, 8/7, and 8/8/23, showed the patient was assessed to have a Stage 1 pressure injury to the bilateral buttocks. However, there was no documented evidence the SN had coordinated or notified the physician of Patient 6’s bilateral buttocks Stage 1 pressure injury. On 11/17/23 at 1100 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was asked if they needed to notify the physician of the pressure injury to the bilateral buttocks. RN 1 replied they should but there was no documentation of the notification or coordination. RN 1 was informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 12/15/21. The patient was certified for home health services during the certification period from 8/12/22 to 10/10/22. The POC, for the certification period from 8/12/22 to 10/10/22, cited SN to complete head to toe assessment each shift and as needed for any changes in condition and to report alteration in skin integrity unresolved by interventions prescribed by physician. Further review of the POC showed the care summary showing the patient had a small open blister on her left ear lobe due to repeated friction with the wheelchair and was prescribed silver sulfadiazine (antibacterial) 1% topical cream, to apply a small amount as needed two times daily to open wound on the left ear. However, review of the SN notes from 8/12/22 to 10/10/22, failed to show documented evidence an assessment of Patient 7's left ear lobe was performed. On 11/17/23 at 1115 hours, an interview and concurrent closed clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions on the SN visit schedule for one of seven sampled patients (Patient 4), creating the risk of not providing the necessary information to this patient. Findings: 1. Review of Patient 4's clinical record was initiated on 11/8/23. The clinical record showed the SOC was 5/26/22. The patient was certified for home health services during the certification periods from 7/20/23 to 9/17/23, and 9/28/23 to 11/16/23. The POC, for the certification period from 9/28/23 to 11/16/23, cited SN visits 90 to 112 hours per week for body system assessment. On 11/8/23 at 0838 hours, a joint home visit with the LVN 2 was conducted to Patient 4's home. LVN 2 was asked for the written instructions regarding the SN visit schedule provided to the patient. LVN 2 replied no, it was verbally discussed with them. The PCG was asked about the written visit schedule, the PCG replied, the LVN would inform her of the visit. Review of the patient's admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 11/8/23 at 1045 hours, an interview and concurrent clinical record review was conducted with LVN 2. LVN 2 was informed and acknowledged the findings. On 11/17/23 at 1340 hours, RN 1 was informed and acknowledged the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the SN provided care and services in accordance with the POC for three of seven sampled patients (Patients 2, 3, and 7), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 3's clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/16/21. The patient was certified for home health services during the certification periods from 8/8/23 to 10/6/23 and 10/7/23 to 12/5/23. Review of the POC for the certification period from 10/7/23 to 12/5/23, cited 32- 40 hours a week for 60 days. In addition, the POC cited SN to provide straight catheterization every two to three hours using a 14 French catheter, followed by 120 ml irrigation. On 11/8/23 at 0901 hours, a joint home visit was conducted with RN 3. RN 3 was observed providing straight catheter care on Patient 3. RN 3 washed her hands, donned gloves, and prepared Patient 3 for the procedure. RN 3 removed the catheter from the package and inserted the catheter into Patient 3. After obtaining urine output, RN 3 removed the catheter, assisted the patient with clean up, doffed her gloves, and washed her hands. The RN did not provide 120 ml water irrigation as per the agency's P&P. On 11/8/23 at 0930 hours, an interview was conducted with RN 3. RN 3 stated they provided the water irrigations in the morning and afternoon. Review of the SN visit notes from 10/9/23 to 11/6/23, showed the bladder irrigations were done at 0800 and 1530 hours. Further review of the clinical record failed to show the SN had performed the bladder irrigations with every straight catheterization, as per POC. On 11/17/23 at 1215 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 11/9/23. The clinical record showed the SOC was 12/15/21. The patient was certified for home health services during the certification periods from 6/13/22 to 8/11/22, and 8/12/22 to 10/10/22. The POC, for certification period from 8/12/22 to 10/10/22, cited SN visits of 32-40 hours a week for 60 days. In addition, the POC also cited SN to give 250 ml of formula 5 times daily by mouth or via bolus or over 30 min via GT as tolerated by patient. However, review of the SN notes from 8/11/22 to 9/22/22, showed the SN provided 240 ml of formula, instead of 250 ml as per POC. On 11/17/23 at 1115 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings. 3. Review of Patient 2's clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/28/21. The patient was certified for home health services during the certification periods from 8/20/23 to 10/18/23, and 10/19/23 to 12/17/23. a. Review of the POC for certification periods from 8/20/23 to 10/18/23, and 10/19/23 to 12/17/23, showed wound care orders may be performed by SN or caregiver. Wound care treatment orders included the posterior scalp, left buttock, right shin, posterior right lower leg, left big toe, scrotum and mid abdomen old surgical wounds. In addition, the POC cited measure and document each wound site weekly and as PRN for changes in wound site and document on the Wound Care Flowsheet. However, review of the SN visit notes during the certification periods from 8/20/23 to 10/18/23 and 10/19/23 to 12/17/23, failed to show the assessment or measurements of Patient 2's wounds were performed consistently. For example: - The SN visit notes dated 8/30 and 8/31/23, showed the skin was intact. - The SN visit notes dated 8/31/23, showed the skin was intact, with a pressure ulcer on the back of head was dressed. - The SN visit notes from 9/1/23 to 9/5/23 showed the skin was intact. - The SN visit note dated 9/13/23, showed the skin was intact with a pressure ulcer to the right calf and posterior head which were dressed and dry; Further review of the clinical record failed to show documented evidence of the wound measurements and assessments performed as per the POC. b. Review of the POC, for certification period from 8/20/23 to 10/18/23, and 10/19/23 to 12/17/23, cited SN visits of 32-40 hours a week for 60 days. In addition, the POC showed SN to provide enteral feedings formula Kate Farms 1.5 Peptide (1463 ml or 4.5 cartons per day); to give first feeding of the day 488 ml of formula over 1 hour at 488 ml/hour via feeding pump; 325 ml of formula three times per day (six hours apart from the first feeding of the day) over one hour at 325 ml/hour via feeding pump; and 250 ml of water after each feed via GT. Review of the SN visit notes from 8/20/23 to 11/7/23, showed Patient 2 was given 325 ml of formula for the first feeding of the day instead of 488 ml as per the POC. On 11/17/23 at 1102 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled staff prepared the accurate and complete clinical notes for two of seven sampled patients (Patients 1 and 6), creating the increased risk of substandard healthcare outcomes to these patients. Findings: 1. Review of Patient 6's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 2/24/23. The patient was certified for home health services during the certification period from 6/19/23 to 8/317/23. * Review of the Recertification OASIS dated 6/15/23, showed the patient was assessed for the last bowel movement. However, the documentation showed the patient's last bowel movement was on 5/18/23, which was more than a month from the recertification assessment. * Review of the SN note dated 8/8/23, showed the patient was assessed to have an edema and blisters on the right and left side of the lower legs. However, the SN assessed the wound as unstageable which was inaccurate. * Review of the SN notes dated 7/18/23, showed the patient was assessed to have a surgical wound in the abdomen. However, the SN assessed the surgical wound in the abdomen as "unstageable." On 11/17/23 at 1100 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 2. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 3/28/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23, and 9/19/23 to 11/17/23. Review of the SN notes dated 10/8, 10/9,10/23,10/30,11/5, 11/6,11/9, and 11/13/23, showed the SN performed the neurological assessment. The assessment included the pupillary reaction. The pupillary reaction was assessed as "no left pupil larger than the right pupil, baseline". However, the assessment was incorrect. On 11/17/23 at 1223 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the responsibility for the day-to-day operations by not implementing the agency's P&P as evidenced by: * The agency failed to ensure the written agreements for one contractor (Contractor 1) included the required elements for the contract as per Title 22. * The agency failed to ensure the orientation, performance evaluations, and pre- employment physicals for three LVNs (LVNs 1, 2, and 3), and two RNs (RNs 1 and 2) were completed as per the agency's P&P. * The agency failed to ensure the complaints filed by the patients/families were resolved within 30 days or soon as per the agency's P&P. These failures had the potential to negatively impact the agency’s operational performance. Findings: Review of the agency’s P&P titled Governing Body revised 12/03/17, showed the governing body will be responsible for establishing and approving written policies and procedures governing overall operations. The agency's Administrator or Designee duties included employing the qualified personnel and to ensure the adequate staff education and evaluation. 1. According to Title 22, Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the following: - The role, if any, of the agency and contractor in the patient assessment, and discharge planning. Review of the written agreement between the agency and Contractor 1 providing therapy was initiated on 11/16/23. The written agreement did not include the role, if any, of the agency and the contracted individual or agency in the patient assessment, and discharge planning. On 11/17/23 at 1353 hours, an interview and concurrent agency document review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 2.a. Review of the agency's P&P titled Orientation- Direct Care Staff revised 10/7/22, showed all direct care staff will participate in an orientation program upon hire or transfer to a new role. New employees must complete all required elements of the orientation program prior to first assignment. Review of RN 2's personnel file showed the date of hire was 1/31.23. Further review of the personnel file failed to show documented evidence RN 1 had completed the orientation program. On 11/16.23 at 1233 hours, an interview and concurrent personnel file review was conducted with the Field Support Manager. The Field Support Manager was informed and acknowledged the findings. b. Review of the agency's P&P titled Personnel Management and Evaluations revised 1/12/21 showed each direct care staff individual will receive ongoing performance feedback from the office clinical leader. The clinical leader will observe all direct care staff performing their job in the home setting. the first annual observation is due by the end of six months from the date of hire and then annually thereafter. Review of the personnel files for LVNs 1, 2, and 3 and RN 2 showed no documented evidence the performance evaluations were completed for these employees. On 11/16.23 at 1233 hours, an interview and concurrent personnel file review was conducted with the Field Support Manager. The Field Support Manager stated the performance evaluations were conducted 90 days after the date of hire. When asked, the Field Support Manager stated it should be written in the policy. The Field Support Manager was informed and acknowledged the findings. c. Review of the agency's P&P titled Hiring of Field Personnel revised 11/16/23, showed the health screening requirements will be verified and/ or completed prior to the start of the first assigned shift as required by policy, contract, state law or regulation. Review of RN 2's personnel file failed to show a pre-employment physical was documented into the RN's personnel file. On 11/16/23 at 1233 hours, an interview and concurrent personnel file review was conducted with the Field Support Manager. The Field Support Manager was informed and acknowledged the findings. 3. Review of the agency's P&P titled Grievances and Complaints revised date 7/14/23 showed grievances received from a patient/ client or family/ caregiver will be promptly reported to office leadership for assessment determination. The grievance investigation shall begin within 2 business days of receipt and the investigation shall be completed within 30 days or sooner if required by law. Review of the agency's grievance log showed the following grievances: - A complaint was filed on 9/12/22, by a patient's family member. Further review of the complaint log showed the complaint was resolved on 11/15/22, 64 days after the complaint filed. - A complaint was filed on 1/11/23, by a patient's PCG. Further review of the complaint log showed the complaint was resolved on 3/8/23. The complaint was resolved 56 days after the complaint filed. - A complaint was filed on 3/23/23 by a patient's PCG. Further review of the complaint log showed the complaint was resolved on 4/26/23, 34 days after the complaint was filed. - A complaint was filed on 12/6/22 by a patient's PCG. Further review of the complaint log showed the complaint was resolved on 1/10/23, 35 days after the complaint was filed. - A complaint was filed on 5/18/23 by a patient's PCG. Further review of the complaint log showed the complaint was resolved on 6/28/23, 41 days after the complaint was filed. The agency failed to ensure the complaints were resolved within 30 days after the complaint was filed as per the agency's P&P. On 11/17/23 at 1403 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

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 agency failed to complete and send the discharge summary to the primary care physician within five days from the discharge order for one of seven sampled patients (Patient 6). This failure created the risk for this patient not receive continuity in care and medical treatment. Findings: Review of Patient 6's closed clinical record was initiated on 11/7/23. The clinical record showed the SOC was 2/24/23. The patient was certified for home health services during the certification period from 6/19/23 to 8/317/23. Review of the physician's order dated 8/14/23, showed a discharge order for Patient 6 from the HHA services. Review of the Fax Notification dated 9/12/23, showed the agency had sent the physician a notification to sign the discharge order. However, review of the clinical record failed to show a discharge summary was sent to the physician five days from the discharge order. In addition, review of the Discharge Summary dated 8/14/23, showed the description of the HHA's services provided. However, the Discharge Summary failed to include the type and frequency of the services provided. On 11/17/23 at 1100 hours, RN 1 was informed and acknowledged the findings.