Every finding on record at Med Plus Home Healthcare, LLC

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that includes the names and contact information of entities providing services under arrangement, and Pt. Physicians. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 4/27//22 at 9:45 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information of entities providing service under arrangement, and Pt. Physicians. 2. During an interview with the Administrator on 4/27/22 at 11:20 AM, the Administrator confirmed the above finding.

42 CFR 484.80(f)(3): Eligible training and competency evaluation organizations. Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.70 Infection prevention and control and 484.105 Organization and Administration of Services Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months effective 04/28/22. This applies even if the agency is not currently conducting aide training and/or competency evaluation. Abbreviations: SOC = Start of Care POC/PsOC = Plan of Care/Plans of Care SN = Skilled Nurse RN = Registered Nurse LPN = Licensed Practical Nurse AM = morning PM = Evening PRN = as needed BID = twice a day % = percent mg/MG = milligram/milligrams mg/dl = milligrams per deciliter PO = by mouth OU = both eyes (>) = greater than (<) = less than Temp = Temperature BP = blood pressure COVID-19 = Coronovirus 2019

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure the SN obtained the patient's signature verifying receipt of their rights and responsibilities at the SOC. This was found in 3 of 7 (Pts. #1, 5 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed as indicated below, and lacked documentation the Pts. acknowledged the receipt of a copy of their rights and responsibilities: Pt. #1. SOC: 1/14/20. The clinical record was reviewed on 4/25/22 at 12:20 PM. Pt. #5. SOC: 4/15/21. The clinical record was reviewed on 4/26/22 at 1:45 PM. Pt. #7. SOC: 8/30/19. The clinical record was reviewed on 4/25/22 at 3:45 PM. 2. During interviews with the Administrator on 4/27/22 at 11:20 AM and 1:40 PM, it was confirmed that the above records lacked documentation the Pts. acknowledged that at the SOC, they received a copy of their rights and responsibilities.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to either obtain informed consents for care and treatment and/or identify the discipline that will provide care, and the frequency of visits. This was found in 7 of 7 clinical records reviewed. (Pts. #1, 2, 3, 4, 5, 6 and 7). Findings Include: 1. The following clinical records were reviewed from from 4/25/22 (12:20 PM) to 4/26/22 (1:45 PM) and lacked the following: Pt. #1. SOC: 1/14/20. Consent for service, initially informed of the discipline to provide service and their frequency at the SOC. Pt. #2. SOC: 10/18/19. Initially informed of the discipline to provide service and their frequency at the SOC. Pt. #3. SOC: 11/1/21. Initially informed of the discipline to provide service and their frequency at the SOC. Pt. #4. SOC: 11/1/21. Initially informed of the discipline to provide service and their frequency at the SOC. Pt. #5. SOC: 4/15/21. Consent for service, initially informed of the discipline to provide service and their frequency at the SOC. Pt. #6. SOC: 2/13/17. Initially informed of the discipline to provide service and their frequency at the SOC. Pt. #7. SOC: 8/30/19. Initially informed of the discipline to provide service and their frequency at the SOC. 2. The Agency policy titled, "Service Agreement" was reviewed on 4/26/22 at 1:50 PM. The policy required, "A Service Agreement shall be developed with all patients upon admission, before care is provided. The service agreement will identify the services to be provided, disciplines providing care..." 3. During interviews with the Administrator on 4/27/22 at 11:20 AM and 1:40 PM, the Administrator confirmed that the above records lacked documentation the Agency failed to either obtain informed consents for care and/or identify the discipline that provided care, and the frequency of visits.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure Pts. were advised of the extent of their financial liability for care, and/or services before care was initiated. This was found in 5 of 7 Pts. (Pts. #1, 3, 5, 6, and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 4/25/22 at 12:20 PM to 4/26/22 at 1:45 PM: Pt. #1. SOC 1/14/20. Pt. #3 SOC 11/1/21. Pt. #5. SOC 4/15/21. Pt. #6. SOC 2/13/17. Pt. #7. SOC 8/30/19. The records lacked documentation the above Pts. were informed of their financial liability for care and/or services, if any, prior to the initiation of care/services. 2. The Agency policy titled “Service Agreement” was reviewed on 4/26/22 at 1:50 PM. The policy required: “A Service Agreement shall be developed with all Patients upon admission, before care is provided. The service agreement will identify the services to be provided…charges and expected sources of reimbursement for services. The Patient will be informed of their liability for payment…” 3. During interviews with the Administrator on 4/25/22 at 11:20 AM and 1:40 PM, the above findings were confirmed.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on observation, clinical record review, review of the Agency’s staff list, interviews during home visits, Agency policy, and staff interview, it was determined the Agency failed to ensure initial comprehensive assessments were performed by an RN and/or performed within 48 hours of a Physician’s referral. This was found in 4 of 7 clinical records reviewed (Pts. #5, 1, 2, and 4). 3. Pt. #1. SOC 1/14/20. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 4/25/22 at 12:20 PM. The record contained the "Patient Profile" and "Referral", both documents included a referral date of 6/7/17. A SOC comprehensive assessment was conducted on 1/14/20. As of 4/25/22, the Agency lacked a referral or Physician order for the SOC conducted on 1/14/20. It cannot be determined whether the SOC was conducted within 48 hours of receipt of a referral. 4. Pt. #2. SOC 10/18/19. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Uncomplicated Asthma. The clinical record was reviewed on 4/25/22 at 1:30 PM. The record contained the Agency's "Referral Form" with a referral date of 4/22/15. A SOC comprehensive assessment was conducted on 10/18/19. As of 4/25/22, the Agency lacked a referral or Physician order for the SOC conducted on 10/18/19. It cannot be determined whether the SOC was conducted within 48 hours of receipt of a referral. 5. Pt. #4. SOC 11/1/21. Diagnoses: Essential (Primary) Hypertension and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 4/26/22 at 12:50 PM. The record contained the "Patient Profile" and "Referral", both documents included a referral date of 7/14/17. A SOC comprehensive assessment was conducted on 11/1/21. As of 4/26/22, the Agency lacked a referral or Physician order for the SOC conducted on 11/1/21. It cannot be determined whether the SOC was conducted within 48 hours of receipt of a referral. 6. The Agency's policy titled, "Comprehensive Patient Assessment" was reviewed on 4/27/22 at 3:25 PM. The policy required: "...1. The Comprehensive Assessment will be completed by a Registered Nurse, except in situations where therapy services are the only service ordered by the physician..." 7. During interviews with the Administrator on 4/27/22 at 11:20 AM and 1:40 PM, the Administrator confirmed that Pts. #1, 2, 3, 4, 5 6, and 7 received only SN services. During the same interview the Administrator confirmed the above findings. Findings include: 1. Upon entrance to the Agency on 4/25/22 at 9:00 AM, the Agency Supervisor was not present. The Administrator was present, and stated the Agency does not currently have an Alternate Agency Supervisor, and the only staff members are himself (also an LPN), the Agency Supervisor, and the Alternate Administrator, who is not a licensed clinician. The Agency’s staff list confirms these are the only current staff members. The Agency Supervisor was not present for the duration of the survey, 4/25/22 to 4/28/22. During a telephone interview on 4/26/22 at 1:45 PM with the Agency Supervisor, the Agency Supervisor stated she does come into the office sometimes, but hasn’t been on home visits to see Pts. since the start of the COVID-19 Pandemic (March of 2020). During an interview with the Administrator on 4/26/22 at 2:10 PM, the Administrator confirmed the Agency Supervisor has not been on home visits to see Pts. since March of 2020, and he has been completing all home visits, including compreshensive assessment visits. During interviews with the Administrator on 4/27/22 at 11:20 AM, the Administrator confirmed the above findings. The Administrator stated he has been completing all the Pt. home visits since March of 2020, writing down the Patients’ vital signs and assessments, then reporting this information to the Agency Supervisor. It is the Agency Supervisor who then completes the documentation of the initial comprehensive assessments. 2. Pt. #5. SOC 4/15/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/26/22 at 1:45 PM. The record included the initial comprehensive assessment dated 4/15/21, signed by the Agency Supervisor.

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: A. Based on observation, staff interview, clinical record review, review of the Agency’s staff list, Agency policy, and staff interview, it was determined the Agency failed to ensure recertification comprehensive assessments were performed by an RN. This was found in 6 of 7 (Pts. #3, 6, 7, 1, 2, and 4) clinical records reviewed. 4. Pt. #1. SOC 1/14/20. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 4/25/22 at 12:20 PM. The record contained a recertification comprehensive assessment with documentation that the RN conducted and completed the assessment on 3/1/22. A home visit was conducted on 4/26/22 at 9:00 AM. During the home visit an interview with was conducted with the Pt. that stated the RN had not visited or provided service since April or May of 2021. 5. Pt. #2. SOC 10/18/19. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Uncomplicated Asthma. The clinical record was reviewed on 4/25/22 at 1:30 PM. The record contained a recertification comprehensive assessment with documentation that the RN conducted the visit and completed the assessment on 4/4/22. A home visit was conducted on 4/26/22 at 10:00 AM. During the home visit an interview was conducted with the Pt. that stated the RN had not visited or provided service since last year. During the same interview with the patient's caregiver, the caregiver could not recall when the last time the RN visited or provided service to Pt. #2. 6. Pt. #4. SOC 11/1/21. Diagnoses: Essential (Primary) Hypertension and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 4/26/22 at 12:50 PM. The record contained a recertification comprehensive assessment with documentation that the RN conducted the visit and completed the assessment on 2/28/22. Based on the interview with the Agency Supervisor on 4/26/22 at 1:45 PM, an on-site visit by the RN was not conducted on 2/28/22. 7. The Agency's policy titled, "Comprehensive Patient Assessment" was reviewed on 4/27/22 at 3:25 PM. The policy required: "...1. The Comprehensive Assessment will be completed by a Registered Nurse, except in situations where therapy services are the only service ordered by the physician..." 8. During interviews with the Administrator on 4/27/22 at 11:20 AM and 1:40 PM, the Administrator confirmed that the RN failed to make on-site visits to complete the recertification comprehensive assessments conducted within the last 5 days of the 60-Day certification period. Findings include: 1. Upon entrance to the Agency on 4/25/22 at 9:00 AM, the Agency Supervisor was not present. The Administrator was present, and stated the Agency does not currently have an Alternate Agency Supervisor, and the only staff members are himself (also an LPN), the Agency Supervisor, and the Alternate Administrator, who is not a licensed clinician. The Agency’s staff list provided confirmed these are the only current staff members. The Agency Supervisor was not present for the duration of the survey, 4/25/22 to 4/28/22. During a telephone interview on 4/26/22 at 1:45 PM with the Agency Supervisor, the Agency Supervisor stated she does come into the office sometimes, but hasn’t been on home visits to see Pts. since the start of the COVID-19 Pandemic (March of 2020). During an interview with the Administrator on 4/26/22 at 2:10 PM, the Administrator confirmed the Agency Supervisor has not been on home visits to see Pts. since March of 2020, and he has been completing all home visits, including recertification comprehensive assessment visits. During interviews with the Administrator on 4/27/22 at 11:20 AM, the Administrator confirmed the above findings. The Administrator stated he has been completing all the Pt. home visits since March of 2020, writing down the Patients’ vital signs and assessments, then reporting this information to the Agency Supervisor. It is the Agency Supervisor who then completes the documentation of the initial comprehensive assessments. 2. Pt. #3. SOC 11/1/21. Primary Diagnosis: Polyarthritis, Unspecified. The clinical record was reviewed on 4/25/21 at 1:10 PM. The record included the recertfication comprehensive assessment dated 2/25/22, and signed by the Agency Supervisor. 3. Pt. #6. SOC 2/13/17. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/25/22 at 2:15 PM. The record included the recertfication comprehensive assessment dated 9/16/21, and signed by the Agency Supervisor. 4. Pt. #7. SOC 8/30/19. Primary Diagnosis: Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 4/25/22 at 3:45 PM. The record included the recertfication comprehensive assessment dated 8/17/21, and signed by the Agency Supervisor.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure PsOC are signed by the Physician within 60 days, and that the POC is followed, as per Physician’s orders. This was found in 5 of 7 (Pt. #5, 6, 7, 2, and 4) clinical records reviewed. 4. Pt. #2. SOC 10/18/19. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Uncomplicated Asthma. The clinical record was reviewed on 4/25/22 at 1:30 PM. The record contained the POC effective 2/4/22 requiring the SN "Notify Physician of vital sign parameters out of range: Heart Rate: Greater Than (>) 90 Less Than () 100.3 Less Than () 23 Less Than () 160 Less Than () 90 Less Than () 90 Less Than () 100.3 Less Than () 23 Less Than () 160 Less Than () 90 Less Than (<) 60... SN to perform complete physical assessment each visit..." The SN visit note dated 3/23/22 lacked any vital signs. The SN visit note dated 3/30/22 lacked the BP, and the SN visit note dated 3/4/22 lacked the BP. 6. During an interview with the Administrator on 4/27/22 at 11:20 AM and 1:40 PM, the Administrator confirmed that the Agency failed to ensure POC were reviewed and signed by the Physician, and staff failed to follow the POC. Findings include: 1. Pt. #5. SOC 4/15/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/26/22 at 1:45 PM. The record included the POC effective 4/15/21 to 6/13/21. The record lacked documentation this POC was ever signed by the Physician. 2. Pt. #6. SOC 2/13/17. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/25/22 at 2:15 PM. The record included the POC effective 9/20/21 to11/18/21. The record lacked documentation this POC was ever signed by the Physician. 3. Pt. #7. SOC 8/30/19. Primary Diagnosis: Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 4/25/22 at 3:45 PM. The record included the POC effective 8/19/21 to10/17/21. The record lacked documentation this POC was ever signed by the Physician.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure Pts. were screened for the Influenza and Pneumococcal Pneumonia vaccines, as required by the Agency. This was found in 6 of 7 (Pts. 1, 2, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 1/14/20. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 4/25/22 at 12:20 PM. The record lacked documentation the SN assessed the patient's need for the Influenza (Flu) and Pneumococcal Pneumonia vaccines at the SOC, and the need for the Influenza vaccine in 2021. 2. Pt. #2. SOC 10/18/19. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Uncomplicated Asthma. The clinical record was reviewed on 4/25/22 at 1:30 PM. The record lacked documentation the SN assessed the patient's need for the Influenza (Flu) and Pneumococcal Pneumonia vaccines at the SOC, and the need for the Influenza vaccine in 2020 and 2021. 3. Pt. #4. SOC 11/1/21. Diagnoses: Essential (Primary) Hypertension and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 4/26/22 at 12:50 PM. The record lacked documentation the SN assessed the patient's need for the Influenza (Flu) and Pneumococcal Pneumonia vaccines at the SOC. 4. Pt. #5. SOC 4/15/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/26/22 at 1:45 PM. The record lacked documentation the Pt. was screened for the status of the influenza and pneumococcal pneumonia vaccines at the SOC. 5. Pt. #6. SOC 2/13/17. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/25/22 at 2:15 PM. The record lacked documentation the Pt. was screened for the status of the influenza and pneumococcal vaccines during 2020 and 2021. 6. Pt. #7. SOC 8/30/19. Primary Diagnosis: Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 4/15/22 at 3:45 PM. The record lacked documentation the Pt. was screened for the status of the influenza and pneumococcal vaccines in 2020 and 2021. 7. The Agency policy titled “Flu/Influenza Vaccine Policy” was reviewed on 4/26/22 at 2:30 PM. The policy required: “…All Pts. will be offered the Flu/Pneumonia vaccination October through April. The Pt. will be asked to sign a form accepting or declining either shot. Procedure: The Flu/Pneumonia shot will be provided by the Patient’s visiting Physician or their Physician of their choice and documented in their medical record…” 8. During interviews with the Administrator on 4/27/22 at 11:20 AM and 1:40 PM, the above findings were confirmed. The Administrator stated Pts. should be screened by the RN for the status of the influenza and pneumococcal vaccines at SOC and during each recertification comprehensive assessment. It should be documented in the clinical record whether the Pt. declines, has already had, or wishes to have these vaccinations. If the Pt. wishes to have the pneumococcal and/or influenza vaccine (during flu season), the Pt. is referred to their Physician for administration of these vaccines.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: A. Based on a review of the Agency's Pt. admission folder, observation and interviews during home visits, clinical record review and staff interview, it was determined the Agency failed to provide information to Pts. regarding the Agency's Clinical Manager (Agency Supervisor). This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency's admission folder was reviewed on 4/25/22 at 11:00 AM, and lacked the name of the Agency Supervisor and their contact information. 2. The clinical records of the following Pts. were reviewed from 4/25/22 (12:20 PM) to 4/26/22 (1:45 PM), and lacked documentation identifying the Agency Supervisor: Pt. #1. SOC: 1/14/20 Pt. #2. SOC: 10/18/19 Pt. #3. SOC: 11/1/21 Pt. #4. SOC: 11/1/21 Pt. #5. SOC: 4/15/21 Pt. #6. SOC: 2/13/17 Pt. #7. SOC: 8/30/19 3. The following home visits were conducted on 4/26/22 from 9:00 AM to 12:10 PM: Pt. #1. SOC: 1/14/20 Pt. #2. SOC: 10/18/19 Pt. #3. SOC: 11/1/21 During the home visits, the Pt. admission folders were observed and lacked documentation identifying the Agency Supervisor. Interviews were conducted with the Pts. #1, 2 and 3 that stated, they were not aware of who is the Agency Supervisor. 4. During interviews with the Administrator on 4/27/22 at 11:20 AM and 1:40 PM, the Administrator confirmed the Agency failed to inform Pts. that Employee #2 was the Agency Supervisor.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: A. Based on a review of personnel files, Agency policy and staff interview, it was determined the Agency failed to ensure all staff are fully vaccinated for COVID-19, policies and procedures were developed and initiated pertaining to the COVID-19 vaccination requirements for staff, providing direct Pt. care and/or services. This was found in 1 of 2 personnel files (Employees #2), and has the potential to affect all Pts. and staff of the Agency. Findings include: 1. In 1 of 2 personnel files reviewed, the Agency lacked the employees COVID-19 vaccination status. The Agency failed to ensure policies and procedures were developed, and initiated pertaining to the COVID-19 vaccination requirements for staff, providing direct Pt. care and/or services (G687). The cumulative effect of these systemic practices resulted in the Agency’s inability to ensure the safety of Pts. and infection control practices of staff.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on a review of personnel files,Agency policy and staff interview,it was determined the Agency failed to ensure all staff are fully vaccinated for COVID-19, and that policies and procedures were developed, and initiated pertaining to the COVID-19 vaccination requirements for staff, providing direct Pt. care and/or services. This was found in 1 of 2 personnel files (Employee #2), and has the potential to affect all Pts. and staff of the Agency. Findings include: 1. The personnel file of Agency Supervisor was reviewed on 4/25/22 at 2:50 PM. The file lacked any documentation of the employee's COVID-19 vaccination status. 2. On 4/25/22 at 2:55 PM, the Administrator presented the policy titled: "COVID-19 Health Care Staff Vaccination Policy". The policy lacked processes and/or implementation for securing: 100% compliance of all staff being fully vaccinated with the COVID-19 vaccine, documentation of tracking staff's COVID-19 vaccination status, temporary delay of receiving the vaccine, development of additional precautions for staff not vaccinated, archival of information of staff not vaccinated and the reason, applicable exemptions for the vaccine, the procedure for requesting COVID-19 vaccine exemption, and the Agency's decision-making process of any exemption requests. 3. During an interview with the Administrator on 4/27/22 at 1:40 PM, the Administrator confirmed the Agency failed to establish the required policies and procedures pertaining to the COVID-19 vaccination staff requirements for employees.

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: A. Based on observations and interviews, policy review, and staff interview, it was determined the Agency failed to ensure it provided an Agency Supervisor or pre-designated alternate available to meet Patient's medical, Nursing, and rehabilitative needs. Findings include: 1. The Agency failed to ensure clinical operations were provided under the direct guidance of an Agency Supervisor or designated Alternate Agency Supervisor, available at all times during the Agency’s operational hours. (G948) 2. The Agency failed to ensure the Agency Supervisor or designated alternate was available to meet Patient's medical, Nursing, and rehabilitative needs during operating hours. (G950) The cummulative effect of these failures has the potential to affect all Pts. receiving services from the Agency.

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: A. Based on observation, staff interview, review of the Agency’s staff list, Pt. interviews conducted during home visits, Agency policy review, and staff interview, it was determined the Agency’s Administrator failed to ensure the Agency’s clinical operations were provided under the direct guidance of an Agency Supervisor or designated Alternate Agency Supervisor, available at all times during the Agency’s operational hours. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. Upon entrance to the Agency on 4/25/22 at 9:00 AM, the Agency Supervisor was not present. A sign posted on the front door of the Agency indicated the Agency was open Mondays through Fridays, 9:00 AM to 5:00 PM. The Administrator was present, and stated the Agency does not currently have an Alternate Agency Supervisor, and the only staff members are himself (LPN), the Agency Supervisor, and the Alternate Administrator, who is not a licensed clinician. The Agency’s staff list provided by the Administrator on 4/27/22 at 9:30 AM confirmed these are the only current staff members. A request was made to speak /meet in person with the Agency Supervisor at 9:30AM,10:45 AM, 12:00 PM, 3:00 PM, and 4:00 PM. The Administrator stated he still hadn’t been able to contact the Agency Supervisor all day. On 4/26/22 at 11:20 AM, a request was again made to speak/meet with the Agency Supervisor, and the Administrator stated she was unavailable, but might call later that day. The Agency Supervisor was not present for the duration of the survey, 4/25/22 to 4/28/22. 2. Home visits with Pts. #1, 2, and 3 were conducted on 4/26/22, along with the Administrator, from 9:00 AM to 11:25 AM. Pts. #1, 2, and 3 did not know who the Agency Supervisor was. 3. During a telephone interview on 4/26/22 at 1:45 PM with the Agency Supervisor, the Agency Supervisor stated she does come into the office “whenever I need to be there.” When asked when was the last time she provided Pt. care or service, the Agency Supervisor replied “because of the Pandemic, I haven’t been going out.” 4. During an interview with the Administrator on 4/26/22 at 2:10 PM, the Administrator confirmed the Agency Supervisor has not been on home visits to see Pts. since March of 2020. 5. The Agency job description titled “Administrator” was reviewed on 4/27/22 at 10:00 AM. The job description required: “...Administrator: Plans, develops, and directs the programs, services, activities and employees of the Agency…Identifies and implements the organizational structure…" 6. The Agency policy titled “Clinical Supervision” was reviewed on 4/27/22 at 9:45 AM. The policy required: “…The Nursing Supervisor or similarly qualified alternate shall be available at all times during operating hours. 7. The Agency policy titled “Agency Supervisor Backup” was reviewed on 4/27/22 at 10:20 AM. The policy required: “…In the event that the Agency Supervisor is not available, a designated, qualified alternate will assume his or her duties and responsibilities, and be available to respond to emergencies…The Agency Supervisor or alternate will be available during hours of operation…” 8. During interviews with the Administrator on 4/27/22 at 11:20 AM, the Administrator confirmed the above findings. The Administrator stated he has been completing all the Pt. home visits since March of 2020.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: A. Based on observation, staff interview, review of the Agency’s staff list, Pt. interviews conducted during home visits, Agency policy review, and staff interview, it was determined the Agency failed to ensure an Agency Supervisor or designated Alternate Agency Supervisor was available during the Agency’s operational hours. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. Upon entrance to the Agency on 4/25/22 at 9:00 AM, the Agency Supervisor was not present. A sign posted on the front door of the Agency indicated the Agency was open Mondays through Fridays, 9:00 AM to 5:00 PM. The Administrator was present, and stated the Agency does not currently have an Alternate Agency Supervisor, and the only staff members are himself (LPN), the Agency Supervisor (RN), and the Alternate Administrator, who is not a licensed clinician. 2. The Agency’s staff list provided by the Administrator on 4/27/22 at 9:30 AM confirmed these are the only current staff members. 3. A request was made to speak /meet in person with the Agency Supervisor at 9:30 AM, 10:45 AM, 12:00 PM, 3:00 PM, and 4:00 PM. The Administrator stated he still hadn’t been able to contact the Agency Supervisor all day. On 4/26/22 at 11:20 AM, a request was once again made to speak /meet with the Agency Supervisor, the Administrator stated she was unavailable, but might call later that day. The Agency Supervisor was not present for the duration of the survey, 4/25/22 to 4/28/22. 4. Home visits with Pts. #1, 2, and 3 were conducted on 4/26/22, along with the Administrator, from 9:00 AM to 11:25 AM. Pts. #1, 2, and 3 did not know who the Agency Supervisor was. 5. During a telephone interview on 4/26/22 at 1:45 PM with the Agency Supervisor, the Agency Supervisor stated she does come into the office “whenever I need to be there.” When asked when was the last time she provided Pt. care or service, the Agency Supervisor replied “because of the Pandemic, I haven’t been going out.” 6. During an interview with the Administrator on 4/26/22 at 2:10 PM, the Administrator confirmed the Agency Supervisor has not been on home visits to see Pts. since March of 2020. 7. The Agency policy titled “Provision for 24-Hour RN Availability” was reviewed on 4/27/22 at 9:30 AM. The policy required: “…Hours of operation are from 8:00 AM to 5:00 PM, Monday through Friday. A Registered Nurse shall be accessible at all times, 24 hours per day, by telephone and/or pager to meet Patient needs. The Registered Nurse will be available to make a home visit, if necessary…A designated Agency Supervisor shall be available for consultation at all times for emergency situations.” 8. The Agency policy titled “Clinical Supervision” was reviewed on 4/27/22 at 9:45 AM. The policy required: “…The Nursing Supervisor or similarly qualified alternate shall be available at all times during operating hours. 9. During interviews with the Administrator on 4/27/22 at 11:20 AM, the Administrator confirmed the above findings. The Administrator stated he has been completing all the Pt. home visits since March of 2020.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure clinical documentation was accurate. This was found in 2 of 7 (Pts. #2, and 4) clinical records reviewed. Findings include: 1. Pt. #2. SOC 10/18/19. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Uncomplicated Asthma. The clinical record was reviewed on 4/25/22 at 1:30 PM. The record contained The SN visit notes dated 2/7/22 to 4/20/22 which included, "Telephone visit performed due to COVID". The record lacked documentation the Pt. experienced any COVID-19 symptoms during this time frame, or that the Pt. was diagnosed with COVID-19. During an interview with the Administrator on 4/27/22 at 1:40 PM, the Administrator stated the SN visit notes were inaccurate that the Pt. was not diagnosed with COVID-19 from February to April 2022, and that all visits during this time frame were conducted on-site in the patient's home. 2. Pt. #4. SOC 11/1/21. Diagnoses: Essential (Primary) Hypertension and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The record contained the SN visit notes dated 3/2/22 to 4/20/22 which included documentation the Pt. had "Wound/s". The SN visit notes lacked a description of the "Wound/s". The recertification comprehensive assessment dated 2/28/22 lacked a description of any wounds. During an interview with the Administrator on 4/27/22 at 1:40 PM, the Administrator stated Pt. #2 does not have any wounds. 3. The Agency policy titled, "Clinical Records/Medical Record Retention" was reviewed on 4/27/22 at 1:40 PM. The policy required: "Clinical records are legal documents containing comprehensive, accurate, and organized information concerning the patient's health and emotional status, treatments, and services..." 4. During an interview with the Administrator on 4/27/223 at 11:20 AM and 1:40 PM, the Administrator confirmed the above findings.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observations and interviews during home visits, Agency policy and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete and accurate. This was found in 3 of 10 (Pts. #1, 2 and 3) clinical records reviewed. Findings include: 1. Pt. #1. SOC 1/14/20. SOC 1/14/20. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 4/25/22 at 12:20 PM. The record contained the form titled, "Medication Profile" completed by the RN and dated 3/2/22 which included, a list of the patient's current medications. A home visit was conducted on 4/26/22 at 9:00 AM with the Administrator. During the home visit the medications were observed and an interview was conducted with the Pt. "Naproxen 500 mg Tablet one Tablet by mouth daily as needed for pain" was observed, the Pt. stated she had taken the medication for at least "1 year". The medication "Atorvastatin 40 mg Tablet Take 1 Tablet by mouth daily at bedtime" was observed, the Pt. stated she had taken the medication for at least the "past 5 years". As of 4/25/22, the "Medication Profile" form lacked Naproxen and Atorvastatin. 2. Pt. #2. SOC 10/18/19. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Uncomplicated Asthma. The clinical record was reviewed on 4/25/22 at 1:30 PM. The record contained the form titled, "Medication Profile" completed by the RN and dated 4/5/22 which had a list of the patient's current medications, including "Divalproex Sodium 500 MG oral Delayed Release 1 Tablet Daily By mouth (PO)". A home visit was conducted on 4/26/22 at 10:00 AM with the Administrator. During the home visit, the Administrator reviewed the patient's medications and stated aloud, the names of medications and the dosage on the labels . Prednisone 5 mg Tablet one Tablet every morning by mouth was mentioned, and bottle label included the date of 01/13/22. Divalproex Sodium 500 MG 1 Tablet two times a day by mouth was mentioned, and the bottle label included the dated of 4/6/22. As of 4/25/22, the "Medication Profile" form lacked Prednisone and documentation that Divalproex Sodium was taken 2 times a day. 3. Pt. #3. SOC 11/1/21. Primary Diagnosis: Polyarthritis, Unspecified. The clinical record was reviewed on 4/25/21 at 1:10 PM. The record contained the Patient’s Medication Profile, dated 2/28/22. The record lacked any Physician’s orders for medication changes subsequent to this date. A home visit was conducted on 4/26/22 at 11:25 AM, along with the Administrator/LPN. During this home visit, the Patient’s medications were reviewed, along with the Medication Profile. The Medication Profile contained the Physician’s order for: “Azelastine 0.05% Opthalmic solution, 1 drop BID OU; Levocetrizine 5 mg daily by mouth; and Vitamin D2, 50,000 units oral capsule once a week by mouth.” The Pt. denied ever taking these medications. The Pt. presented the following medication, not listed on the Medication Profile: Meloxicam 7.5 mg, with the directions to take 1 tablet by mouth daily. The Pt. stated she started taking this medication “since the beginning of April (2022).” The Pt. also presented a bottle of Amytriptyline 10 mg, with the directions to take one tablet by mouth every night at bedtime. The Pt. stated she has been taking this medication “more than a year.” The Pt. also presented a bottle of Guaifenesin 400 mg tablets, with the direction to take one tablet every 4 hours, as needed. The Pt. stated she has been taking this medication “more than a year.” The Medication Profile was inaccurate. 4. The Agency policy titled “Medication Profile” was reviewed on 4/26/22 at 3:00 PM, The policy required: “…The Nurse/Therpist shall record on the Medication Profile all prescribed and over-the-counter medications the Patient is currently taking…If the Physician changes the medication orders, the Nurse must add newly-ordered drugs or medication changes to the Medication Profile. Discontinued medications shall be highlighted and documented as “DC” with the appropriate date…” 5. During interviews with the Administrator on 4/27/22 at 11:20 AM and 1:30 PM, the above findings were confirmed. The Administrator stated if the Pt. reports any new medications/changes in medications, the Physician is notified for orders and the Medication Profile is updated accordingly.

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: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure discharge summaries were completed by the SN and sent to the Physician within 5 days of discharge from the Agency. This was found in 3 or 7 (Pts. #5, 6, and 7) clinical records reviewed. Findings include: 1. Pt. #5. SOC 4/15/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/26/22 at 1:45 PM. The record included the 5/24/21 Physician’s order: “Discharge per Patient request. Patient and Family Caregiver requested discharge.” The record lacked documentation the SN completed a discharge summary and sent it to the Physician. 2. Pt. #6. SOC 2/13/17. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/25/22 at 2:15 PM. The record included the 2/27/22 Physician’s order: “Discharge due to death. Patient died at home.” The record lacked documentation the SN completed a discharge summary and sent it to the Physician. 3. Pt. #7. SOC 8/30/19. Primary Diagnosis: Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 4/25/22 at 3:45 PM. The record included the 10/4/21 Physician’s order: “Discharge due to death.” The record lacked documentation the SN completed a discharge summary and sent it to the Physician. 4. The Agency policy titled “Discharge Summary” was reviewed on 4/26/22 at 2:15 PM. The policy required: “When a Patient is discharged from the Agency, the supervising professional shall complete a discharge summary within the time frame defined by the Agency. A copy will be mailed to the Physician…” 5. During an interview with the Administrator on 4/27/22 at 11:20 AM, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure documentation entered into the clinical record was complete. This was found in 4 of 7 (Pts. # 1, 2, 3 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 1/14/20. SOC 1/14/20. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 4/25/22 at 12:20 PM. The record contained documentation the SN provided service one time a week from 3/3/22 to 4/21/22. The SN visit note dated 3/8/22 lacked documentation the SN inquired or tested the patient's blood sugar during this visit. During an interview with the Administrator on 4/27/22 at 1:40 PM, the Administrator stated for diabetic patients, the nurse is required during each visit to assess the patient's blood sugar. Either ask the Pt. for the blood sugar results obtained earlier during that day, or the nurse use the patient's glucometer to assess the patient's blood sugar. 2. Pt. #2. SOC 10/18/19. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Uncomplicated Asthma. The clinical record was reviewed on 4/25/22 at 1:30 PM. The record contained documentation the SN provided service one time a week from 3/2/22 to 4/20/22. The SN visit note dated 3/23/22 lacked documentation the SN inquired or tested the patient's blood sugar during this visit. 3. The Agency's policy titled, "Documentation of Changes To The Medical Record" was reviewed on 4/28/22 at 9:57 AM. The policy included: "Documentation provides evidence that the agency provided the patient services... Accuracy and correct documentation... are critical components..." 4. During an interview with the Administrator on 4/27/22 at 1:40 PM, the Administrator confirmed documentation entered into the clinical records indicated above were incomplete. 3. Pt. #3. SOC 11/1/21. Primary Diagnosis: Polyarthritis, Unspecified. The clinical record was reviewed on 4/25/21 at 1:10 PM. The record contained the SN visit note dated 3/1/22, which lacked documentation of the Patient’s heart rate and blood pressure. The record contained the SN visit notes dated 3/10/22 and 4/14/22, which lacked an assessment of the Patient’s pain level. The record also contained the SN visit note dated 4/21/22, which lacked documentation of the Patient’s heart rate. 4. Pt. # 7. SOC 8/30/19. Primary Diagnosis: Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 4/25/22 at 3:45 PM. The record contained the SN recertification assessment dated 8/17/21, which lacked documentation of the Patient’s heart rate and oxygen saturation level. The record included the SN visit note dated 9/23/21, which lacked documentation of the Patient’s blood sugar level. The record also contained the SN visit note dated 9/30/21, which lacked documentation of the Patient’s blood sugar level and pain assessment. During an interview with the Administrator/LPN on 4/27/22 at 11:20 AM, the Administrator stated he performed the above SN visits for Pts. #3 and 7, and took all vital signs, blood sugar levels, pain assessment levels, heart rate, and oxygen saturation levels, but failed to document these findings in the Patients' clinical records.