Every finding on record at Memorialcare Home Health, LLC

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; 39539 HFEN; and 39210, HFEN. The survey team entered the HHA on 6/14/22 at 0900 hours. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: P&P: Policy and Procedure QM: Quality Manager

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure their comprehensive emergency preparedness program included a facility based risk assessment, utilizing an all hazards approach. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 6/14/22. The agency's P&P tiled Emergency Preparedness Program revised date 5/24/22, showed an environmental hazards assessment was completed. However, the agency's emergency preparedness plan failed to include a facility based risk assessments and strategies for addressing hazards or emergency events identified by the facility and community risk assessments. On 6/22/22 at 1145 hours, an interview and concurrent document review was conducted with the QM. The QM was informed and acknowledged the finding.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to follow up with on-duty staff and patients to determine services needed and procedures to inform state and local officials of any on-duty staff or patients they are unable to contact. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 6/14/22. The agency's Emergency Preparedness Program reviewed 5/24/22, showed the One Call Now System will be used to reach out to on duty staff, requesting further information about any patient services that were interrupted. Staff that are at home or in the field at the time of a disaster will contact the Home Health office as soon as possible by regular or cellular phones, fax line, or with the assistance of local emergency management official's radios to receive assignment and maintain communication However, the agency's Emergency Preparedness Plan P&P did not include the procedures to follow up with any on-duty staff or patients they are unable to contact, or procedures to communicate with state and local officials of any on duty staff or patients they are unable to contact. On 6/22/22 at 1145 hours, an interview and concurrent document review was conducted with the QM. The QM was informed and acknowledged the above findings.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P addressed a system of medical documentation that protected confidentiality of the patient information, and secured and maintained availability of records. This created the potential risk of not protecting the patient's confidential information during the emergency. Review of the agency's Emergency Preparedness Program was conducted on 6/14/22. The agency's Emergency Preparedness Program did not address a system of medical documentation that protected confidentiality of patient information, and secured and maintained availability of records. On 6/22/22 at 1145 hours, an interview and concurrent document review was conducted with the QM. The QM was informed and acknowledged the finding.

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: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included the updated name and contact information of the entities provided services under agreement, patients' physician, and volunteers. This failure had the potential to negatively impact the patients' care needs during the emergency events. Review of the agency's Emergency Preparedness Program was conducted on 6/22/22. The agency's Emergency Preparedness Program showed the agency will utilize the One Call Now System to reach to on duty staff. However, the agency's emergency preparedness program did not include the addresses, names, and contact information of the entities providing services under agreement, patients' physician, and volunteers. On 6/22/22 at 1145 hours, an interview and concurrent document review was conducted with the QM. The QM was informed and acknowledged the findings.

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), §485.625(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 name and information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. This failure had the potential to negatively impact the patients' care needs during the emergency events. Review of the agency's emergency preparedness policy and plan was conducted on 6/15/22. The agency's emergency preparedness plan did not include the contact information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. On 6/22/22 at 1145 hours, an interview and document review was conducted with the QM. The QM was informed and acknowledged the finding.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure initial training in the emergency preparedness program was provided to volunteers and contracted individuals providing services under arrangement and documentation of all the emergency preparedness training was maintained. This failure created the risk of the HHA's staff not knowing what to do in case of emergency. Review of the agency's Emergency Preparedness Program revised dated 5/24/22 was conducted on 6/14/22. The agency's P&Ps did not address the requirement to provide initial emergency preparedness training to the volunteers and contracted individuals. In addition, there was no documented evidence the initial emergency preparedness training was provided to the volunteers and contracted individuals. The agency was not able to provide documented evidence of emergency preparedness training for existing staff. On 6/22/22 at 1145 hours, an interview and concurrent document review was conducted with the QM. The QM was informed and acknowledged the findings.

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; 39539, HFEN; and 39210, HFEN. The survey team entered the HHA on 6/14/22 at 0900 hours. The survey team conducted 7 home visits and reviewed 12 active and 5 closed clinical records. Glossary: AKA: above knee amputation BID: two times a day BP: blood pressure bpm: beats per minute cc: cubic centimeter CHHA: Certified Home Health Aide coccyx: tailbone Diastolic blood pressure: the second number or bottom number, indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats F: Fahrenheit HHA: Home Health Agency Indwelling urinary catheter: a tube inserted into the bladder to drain urine LVN/LPN: Licensed Vocational Nurse/ Licensed Practical Nurse M: Month mcg: microgram(s) mEq: milliequivalent mg: milligram(s) mmHg: millimeter(s) of mercury NS: Normal Saline OASIS: Outcome and Assessment Information Set PI: Performance Improvement P&P: Policy and Procedure PCG: Patient Caregiver PI: Performance Improvement PO: by mouth POC: Plan of Care PRN: As Needed PT: Physical Therapy/Therapist PTA: Physical Therapy Assistant Q: Every QAPI: Quality Assurance and Performance Improvement (process used to ensure services are meeting quality standards) QD: daily QM: Quality Manager SN: Skilled Nursing/Nurse Stage 2 Pressure Injury: Partial thickness loss of skin with exposed dermis Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer SOB: Shortness of Breath SOC: Start of Care Systolic Blood Pressure: the first number or top number; indicates how much pressure your blood is exerting against your artery walls when the heart beat TID: three times a day Unstageable Pressure Injury: full thickness tissue loss VPCO: Vice President of Clinical Operations W: Week

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 agency failed to ensure the medication profiles were updated for four of 17 sampled patients (Patients 12, 13, 14, and 16), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. 3. Review of Patient 16's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 1/28/22. The patient was certified for home health services during the certification period from 5/28/22 to 7/26/22. The POC, for the certification period from 5/28/22 to 7/26/22, cited SN visits 1W9. The Medication Profile showed the patient’s medications included the following: - Aspirin 81mg, PO, 1 tablet, QD; - Atorvastatin 20mg PO, 1 tablet, QD; - Duloxetine 60mg, PO, 1 tablet, QD; - Ferrous Sulfate 325mg, PO, 1 tablet, TID; - Folic Acid 1mg, PO, 1 tablet, QD; - Gabapentin 600mg, PO, 1 tablet, BID; - Ipratropium- Albuterol inh, 1 dose, Q6hrs PRN SOB; - Potassium Chloride 20 MEQ, 1 tablet, PO, BID; - Metoprolol 50mg, PO, 1 tablet, QD; - Bumetanide 1mg, PO, 1 tablet, BID; - Docusate Calcium 240mg, PO, 1 tablet, BID; - Metolazone 5mg, PO, 1 tablet, QMWF; and - Metolazone 5mg, PO, 1 tablet, QD On 6/16/22 at 1210 hours, a joint home visit was conducted with the HHA 1 to Patient 16's home. Review of the patient’s medications with the HHA and the Pt showed the following: - Medication Profile in the patient's agency's folder was blank; -Metoprolol 50mg had an expiration date of 4/22; - The following medications were not listed in the medication profile: Famotidine 40mg, PO, 1 tablet, QD; Clopidogrel 75mg PO, 1 tablet, QD; Vitamin D3 5000IU, PO, 1 Tablet, QD; and Alendronate 70mg, PO, Qwk. On 6/22/22 at 0954 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant was informed and acknowledged the findings. 4. Review of Patient 12's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 3/14/22. The patient was certified for home health services during the certification period from 3/14/22 to 5/2/22. The POC, for the certification period from 3/14/22 to 5/2/22 , cited SN visits 1W1, 2W9, 3 visits PRN dressing malfunction The Medication Profile showed the patient’s medications included methocarbamol 500mg, PO, 3 tablets, four times a day. On 6/16/22 at 0900 hours, a joint home visit was conducted with the RN to Patient 12's home. Review of the patient’s medications with the HHA and the Pt showed methocarbamol 750mg, PO, 2 tablets, every six hours. On 6/22/22 at 0954 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant was informed and acknowledged the findings. 1. Review of the P&P titled Medication Profile/Drug Regimen Review dated 5/24/22, showed new or changed prescription medications will be added to the medication profile and noted with the code new, existing, or changed. Review of Patient 13's clinical record was initiated on 6/15/22. The clinical record showed the SOC was 5/23/22. The patient was certified for home health services during the certification period from 5/23/22 to 7/21/22. The POC, for the certification period from 5/23/22 to 7/21/22, cited PT/PTA visits 2W4 and SN visits 1W1, 2W2, and 2W4. The Medication Profile showed the patient’s medications included the following: -Sinemet (used to treat Parkinson’s disease) 25-100 mg PO TID; -bupropion (antidepressant) 150 mg PO every night at bedtime; -Cholecalciferol (supplement) 125 mcg PO QD; -vitamin B complex (supplement) one tablet PO QD; -Berberine Complex (used to regulate cholesterol and high blood pressure) one capsule PO QD; -cyanocobalamin ER (supplement) 1000 mcg PO three times per week; -pantoprazole (used to decrease the acid produced in the stomach) 40 mg PO QD; and -simvastatin (used to treat high cholesterol) 10 mg PO QD. On 6/15/22 at 1330 hours, a joint home visit was conducted with PT 1 to Patient 13's home. Review of the patient’s medications with the PT and PCG showed the patient was also taking magnesium threonate two capsules PO QD; however, this medication was not listed in the patient’s medication profile. On 6/15/22 at 1415 hours, an interview and concurrent clinical record review was conducted with PT 1. PT 1 was informed and acknowledged the finding. 2. Review of Patient 14's clinical record was initiated on 6/16/22. The clinical record showed the SOC was 4/27/22. The patient was certified for home health services during the certification period from 4/27/22 to 6/25/22. The POC, for the certification period from 5/23/22 to 7/21/22, cited SN visits 4W1, 7W1, then 2W7. The Medication Profile showed the patient’s medications included lisinopril (used to treat high blood pressure) 10 mg PO QD and biotin (supplement) 1000 mcg PO QD. On 6/16/22 at 1022 hours, a joint home visit was conducted with RN 1 to Patient 14's home. Review of the patient’s medications with RN 1 and the PCG showed the patient was not taking the lisinopril and biotin anymore; however, they were still listed in the patient’s medication profile. The PCG stated the patient stopped taking the medications on the last week of April. On 6/16/22 at 1211 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

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, the agency failed to ensure the comprehensive assessment was completed within the last five days of every 60 days for one of 17 sampled patients (Patient 3). This failure created the increased risk of not addressing the care needs for the patient. Review of Patient 3’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 10/21/21. The patient was certified for home health services during the certification periods from 10/21/21 to 12/19/21, and 12/20/21 to 2/17/22. Further review of Patient 3’s clinical record showed the comprehensive assessment was not completed timely as the OASIS Nurse Recertification assessment was signed and dated on 12/26/21, seven days after the end of the certification period. On 6/22/22 at 0924 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POCs addressed specific interventions related to the patient’s care and treatment for three of 17 sampled patients (Patients 3, 7, and 17). These failures created the risk for the patients not receiving the individualized care and services necessary to improve the patients’ health status. Review of the agency's P&P titled Care Planning dated 5/24/22, showed the care plan should detail specific interventions and education as well as measurable outcomes and goals identified by the agency and patient. 1. Review of Patient 3's clinical record was initiated on 6/15/22. The clinical record showed the SOC was 10/21/21. The patient was certified for home health services during the certification periods from 10/21/21 to 12/19/21, and 12/20/21 to 2/17/22. a. The POC, for the certification periods from 10/21/21 to 12/19/21 and 12/20/21 to 2/17/22, showed nystatin (antifungal) 100,000 unit per gram external application PRN was included in Patient 3’s medication list. However, there was no indication for the use of this medication. b. Further review of Patient 3’s clinical record showed the patient had medical conditions related to the cardiovascular and integumentary systems. The POC, for the certification period from 10/21/21 to 12/19/21, showed the goal for the cardiovascular was for the patient’s weight to be maintained and the goal for the integumentary systems was for the wound to be healed or decrease in size by the end of the certification period. However, the goals listed were not specific or measurable. The goals did not specify the parameters of the weight and the size of the wound. On 6/22/22 at 0924 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the findings. 2. Review of Patient 7's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 2/10/22. The patient was certified for home health services during the certification period from 4/11/22 to 6/9/22. The POC, for the certification period from 4/11/22 to 6/9/22, showed Patient 7 had wounds to the right second toe and right fifth toe; however, the goals for these wounds were not addressed in the POC. On 6/22/22 at 1040 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding. 3. Review of Patient 17’s clinical record was initiated on 6/17/22. The clinical record showed the SOC was 4/1/22. The clinical record showed the patient received home health services during the certification period from 5/31/22 to 7/29/22. The POC, for the certification period from 5/31/22 to 7/29/22, showed to administer acetaminophen (pain reliever) 325 mg one to two tablets PO PRN for pain or fever; however, there was no specific indication showing the parameters for pain or temperature. On 6/22/22 at 1227 hours, an interview and concurrent clinical record review was conducted with the VPCO. The VPCO was informed of the finding.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded 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 physician’s orders related to wound care treatment were included in the POC for three of 17 sampled patients (Patients 2, 3, and 12). This failure created the risk of not providing the appropriate treatment to the patients which could worsen their overall health outcome. 3. Review of Patient 12’s clinical record was initiated on 6/20/22. The clinical record showed the SOC was 3/4/22. The patient was certified for home health services during the certification period from 3/4/22 to 5/2/22. The POC, for the certification period from 3/4/22 to 5/2/22 , showed Patient 12 had a pressure injury to the coccyx. The POC showed treatment per Wound Care Specialist once evaluation done. Further review of the POC and clinical record failed to show the specific treatment and frequency for the pressure injury. Review of the Skilled Nurse Visit Notes dated 3/11, 3/14, 3/17, 3/21, 3/28, 3/31, showed treatment was provided to the wound on the coccyx. Further review of the SN clinical document showed the SN cleansed the wound with wound cleanser, packed the wound with Silver alginate, and covered the wound with layers of ABD (abdominal gauze, used for heavy draining wounds) pads. Further review of the patient's clinical record failed to show a physician's order for the treatment of the pressure injury. On 6/22/22 at 1102 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant verified the finding. b. Review of the SN Visit Note dated 4/25/22, showed Patient 12 was noted to have a stage 4 pressure ulcer injury to the Right Heel. Further review of the clinical record showed the SN provided wound including cleansed wound with normal saline, patted dry, packed with Dakin solution, and covered wound with a dry dressing. However, further review of the clinical record failed to show a physician's order for the wound treatment to the right heel. On 6/22/22 at 1102 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant verified the finding. 1. Review of the document provided by the agency titled Wound Care Documentation Guidelines for Medicare Coverage (undated) showed the plan of care must contain specific instructions for the treatment of the wound. Review of Patient 2’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 11/19/21. The patient was certified for home health services during the certification period from 1/18/22 to 3/18/22. The POC, for the certification period from 1/18/22 to 3/18/22, showed Patient 2 had an unstageable wound to the right lower extremity; however, the POC did not specify the treatment order for the wound. On 6/22/22 at 0904 hours, an interview and concurrent clinical record review was conducted with the QM. The QM verified the finding. 2. Review of Patient 3’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 10/21/21. The patient was certified for home health services during the certification period from 10/21/21 to 12/19/21. The POC, for the certification period from 10/21/21 to 12/19/21, showed Patient 3 had a wound to the buttock. The POC showed to off load and keep the dressing clean, dry, and intact and to perform the wound treatment daily. However, the POC did not include the specific treatment order for the wound. On 6/22/22 at 0924 hours, an interview and concurrent clinical record review was conducted with the QM. The QM verified the finding.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the physician's verbal orders were signed and dated by the qualified staff for furnishing or supervising the care for three of 17 of sampled patients (Patients 2, 4, and 5), creating the risk of not providing appropriate, consistent, and quality care to these patients. 3. Review of Patient 4's closed clinical record was initiated on 6/16/22. The clinical record showed the SOC was 2/28/21. The patient was certified for home health services during the certification period from 6/28/21 to 8/26/21. The patient was discharged on 8/19/21. Review of Patient 4's Plan of Care dated 6/29/21, showed the orders were signed and dated on 6/29/21 at 1357 hours by an RN. However, further review of the clinical record showed the physician signed the order on 8/9/21. On 6/22/22 at 1127 hours, an interview with concurrent closed clinical record review was conducted with the VPCO. The VPCO was informed and acknowledged the findings. 1. Review of the P&P titled Physician Orders dated 5/24/22, showed all physician orders, including the plan of care, will be documented and signed by the physician unless an original written order is attached. Telephone/verbal orders will update the plan of care. The original orders will be sent to the physician for signature and the copy will be retained on the clinical record until the physician signs the original and it is incorporated into the clinical record. Review of Patient 2’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 11/19/21. The patient was certified for home health services during the certification period from 3/19/22 to 5/17/22. The POC, for the certification period from 3/19/22 to 5/17/22, showed the orders were received and electronically signed by the RN on 3/17/22; however, there was no documented evidence showing the physician had signed the POC. On 6/22/22 at 0904 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding. 2. Review of the HHA state regulation Title 22 Chapter 6 74697 (a) showed a written plan of treatment shall be established for each patient whose care requires medical orders. A plan of treatment or plan or care for patients requiring medical orders shall be (a) approved and signed within 30 working days by the attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice. Review of Patient 5’s clinical record was initiated on 6/16/22. The clinical record showed the SOC was 12/22/20. The patient was certified for home health services during the certification period from 4/21/21 to 6/19/21. The POC, for the certification period from 4/21/21 to 6/19/21, showed the orders were received and electronically signed by the RN on 4/19/21; however, the POC was signed by the physician on 7/12/21. On 6/22/22 at 0945 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to communicate with the physician about the patients' care needs for two of 17 sampled patients (Patients 5 and 6). This failure created the risk of not providing the necessary care and services to these patients. 2. Review of the P&P titled Provided Services dated 5/24/22, showed professional nursing services shall be given in accordance with state and federal regulations with the attending physician's orders and shall include but not be limited to communicating to medical provider any appropriate findings or updates as needed. The SN will assess patient status and will place the call to the physician as findings occur. Review of Patient 5’s clinical record was initiated on 6/16/22. The clinical record showed the SOC was 12/22/20. The patient was certified for home health services during the certification period from 2/20/21 to 4/20/21. The POC, for the certification period from 2/20/21 to 4/20/21, showed to assess all vital signs, body systems and to report signs and symptoms necessitating medical attention to the physician. Review of the Skilled Nurse Visit Notes showed the following: -on 2/22/21, the patient’s heart rate was 122; -on 3/1/21, the patient’s heart rate was 117; -on 3/15/21, the patient’s heart rate was 113; -on 3/22/21, the patient’s heart rate was 90; -on 3/29/21, the patient’s heart rate was 129; -on 4/5/21, the patient’s heart rate was 91; and -on 4/12/21, the patient’s heart rate was 72. Review of the Skilled Nurse Visit Notes dated 2/22, 3/1, 3/15, and 3/29/21, revealed no documented evidence showing the SN had reassessed or notified the physician of Patient 5’s increased heart rates. On 6/22/22 at 0945 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding. 1. Review of Patient 6’s clinical record showed the SOC was 10/15/21. The clinical record showed the patient received home health services during the certification period from 4/13/22 to 6/11/22 and 6/12/22 to 8/10/22. The POC, for the certification period from 4/13/22 to 6/11/22, showed the following interventions for wound care: - Assess/ perform/ instruct patient/ PCG pn measure tp prevent skin breakdown, including proper positioning techniques, frequent position changes, hygiene, skin inspection, skin care, increase protein in diet. - Assess/ instruct wound care for stage 4 pressure injury to the sacrum, with treatment to cleanse the wound with normal saline or wound cleanser, apply collagen powder, and covered with bordered foam 2x a week or PRN for loss of integrity and - Wound nurse to consult and collaborate with RN Case Manager and physician. Review of the SN Visit Note dated 5/11/22, showed Patient 6 was noted with a new open blister on right AKA. Review of the SN Visit Note dated 5/18/22, showed Patient 6's Right distal stump was noted as a stage 4 pressure injury. Further review of the clinical record showed a new wound treatment was implemented. Review of Patient 6's physician's orders dated 5/18/22, showed to assess/ perform/ instruct wound care to the right distal stump, stage 4 medical device related pressure injury. The treatment included to cleanse with wound cleanser, apply collagen powder to base, cover with bordered foam, three times a week to be performed by the skilled nurse/ PCG/ patient. Patient/ PCG to perform wound care once competency demonstrated. Review of the SN Visit Notes dated from 5/23, to 6/15. showed the SN provided wound care to the stage 4 pressure injury to the right distal stump. Review of the SN Visit Note dated 6/20/22, noted the pressure injury to the right distal stump as an unstageable pressure injury and wound care treatment was provided with wound cleanser, dressing with collagen powder, and a mepilex bordered dressing was applied. However, further review of the clinical record failed to show the SN notified the physician of the change in condition of the wound. On 6/2/22, at 1152, an interview and concurrent clinical record review was conducted with the VPCO. The VPCO was informed and acknowledged the finding.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the PCG was provided with proper education regarding wound care management for one of 17 sampled patients (Patient 2). This failure created the risk of not providing the appropriate care and services to the patient. Review of the agency's document titled Wound Care Documentation Guidelines for Medicare Coverage (undated) showed teaching of the specific wound care and return demonstration of wound care by the patient/caregiver should be documented. Return demonstration by the patient/caregiver is required prior to the patient/caregiver performing wound care when nurse is not present. Review of Patient 2’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 11/19/21. The patient was certified for home health services during the certification periods from 3/19/22 to 5/17/22, and 1/18/22 to 3/18/22. The POC, for the certification periods from 3/19/22 to 5/17/22, and 1/18/22 to 3/18/22, cited SN visits 1W9 to perform wound care weekly, and for the family to change the dressing on the other time of the week and PRN for soilage or dislodgement. Wound care was to be performed by the patient/caregiver once competence was demonstrated. Review of the Skilled Visit Nurse Notes showed the SN provided wound care management teaching to the patient/caregiver. However, there was no documented evidence showing the SN had assessed the caregiver’s competency skills related to wound care. In addition, the SN had identified the patient/caregiver needed further education. For example, the Skilled Nurse Visit Notes dated 3/30/22, showed the patient was forgetful and the caregiver had a fair understanding of the interventions and education provided by the SN. However, there was no documented evidence showing the SN had reassessed the caregiver’s competency skills nor was there any documentation showing a return demonstration was performed by the caregiver to ensure proper wound care management provided to the patient. On 6/22/22 at 0904 hours, an interview and concurrent clinical record review was conducted with the QM. The QM verified the finding.

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 written SN visit schedule for three of 17 sampled patients (Patients 13, 15, and 16), creating the risk of not providing the necessary information to these patients. 3. Review of Patient 16's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 1/28/22. The patient was certified for home health services during the certification period from 5/28/22 and 7/26/22. The POC, for the certification period from 5/28/22 and 7/26/22 , cited SN visits 1W9. A joint home visit with the HHA was conducted on 6/16/22 at 1210 hours, to Patient 16's home. HHA and Patient 16 was asked for the written instructions outlining the SN visit schedule. Patient 16 replied there was no written instruction outlining the SN visit schedule provided to the patient. Patient 16 stated the SN would call a day prior to visiting the patient’s home. 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 6/22/22 at 0954 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant was informed and acknowledged the findings. 1. Review of the P&P titled Coordination of Care dated 5/24/22, showed the patient and caregiver will receive information on the visit schedule including frequency of visits by the HHA. Review of Patient 13's clinical record was initiated on 6/15/22. The clinical record showed the SOC was 5/23/22. The patient was certified for home health services during the certification period from 5/23/22 to 7/21/22. The POC, for the certification period from 5/23/22 to 7/21/22, cited PT/PTA visits 2W4 and SN visits 1W1, 2W2, and 2W4. A joint home visit with PT 1 was conducted on 6/15/22 at 1330 hours, to Patient 13's home. PT 1 was asked for the written instructions outlining the PT and SN visit schedule. PT 1 was able to provide the written instruction outlining the PT visit schedule provided to the patient; however, review of the patient’s admission packet provided by the HHA showed no documented evidence showing the SN visit schedule. On 6/15/22 at 1400 hours, an interview was conducted with Patient 13’s PCG. The PCG stated the SN did not provide any written instructions outlining the SN’s visit schedule. The PCG stated the SN would call the day before to schedule the home visit. On 6/15/22 at 1405 hours, an interview and concurrent clinical record review was conducted with PT 1. PT 1 was informed and acknowledged the finding. 2. Review of Patient 15's clinical record was initiated on 6/16/22. The clinical record showed the SOC was 4/30/22. The patient was certified for home health services during the certification period from 4/30/22 to 6/28/22. The POC, for the certification period from 4/30/22 to 6/28/22, cited SN visits 2W2 and 1W6. A joint home visit with LVN 1 was conducted on 6/16/22 at 1100 hours, to Patient 15's home. LVN 1 was asked for the written instructions outlining the SN visit schedule. LVN 1 replied there was no written instruction outlining the SN visit schedule provided to the patient. LVN 1 stated she only called the patient prior to visiting the patient’s home. 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 6/16/22 at 1135 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to maintain the infection control data as part of the QAPI program. This failure created the risk of not identifying the appropriate action plans related to infection control, which could lead to substandard healthcare outcomes in the agency. Review of the agency's P&P titled QAPI Program dated 1/24/19, showed the documentation of the QAPI program includes all quality performance improvement projects being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Review of the QAPI program for 2019, 2020, 2021, and 2022 was conducted on 6/22/22. The QAPI program showed the agency performed several PI projects each year which were discussed quarterly during the QAPI meetings. Further review of the QAPI program showed the quality indicators collected for each PI project. For example, the Quality Indicator Dashboard data for 2019 showed the agency’s actual compliance for hand hygiene was 100%. The agency was able to provide the data showing how the agency came up with the actual percentages after each quarter except for infection control, including the data for hand hygiene, vehicle/bag inspection, and proper cleansing of medical equipment after use. On 6/22/22 at 0817 hours, an interview and concurrent record review was conducted with the VPCO. The VPCO verified the finding.

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 skilled professionals provided care and services in accordance with the POC for eleven of 17 sampled patients (Patients 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, and 16). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. 8a. Review of Patient 3’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 10/21/21. The patient was certified for home health services during the certification periods from 10/21/21 to 12/19/21 and 12/20/21 to 2/17/22. The POC, for the certification periods from 10/21/21 to 12/19/21 and 12/20/21 to 2/17/22, showed to assess, perform, and instruct the patient/caregiver to weigh the patient every week and to record the weight. The POC showed to notify the physician for a weight gain greater than five pounds overnight or greater than 10 pounds per week. Review of Patient 3’s clinical record showed the SN visited the patient’s home on 10/23, 10/29, 11/1, 11/6, 11/11, 11/13, 11/15, 11/22/21, 1/5 and 1/15/22. However, the Skilled Nurse Visit Notes showed no documented evidence of the patient’s weight nor the information showing whether the patient had lost, gained, or maintained the weight. b. The POC, for the certification period from 10/21/21 to 12/19/21, showed to assess all vital signs, body systems, and report signs/symptoms necessitating medical attention to the physician. Review of the Skilled Nurse Visit Notes dated 11/15 and 12/11/21, showed no documented evidence the SN assessed the patient’s complete vital signs. For example, on 11/15/21, the SN did not document the patient’s blood pressure, temperature, and respiratory rate. c. The POC, for the certification period from 10/21/21 to 12/19/21, cited SN visits 1W1, 2W4, then 1W5; however, there was no documented evidence showing the SN visited Patient 3’s home from 12/12 to 12/19/21. d. The POC, for the certification periods from 12/20/21 to 2/17/22, cited SN visits 1W8; however, there was no documented evidence showing the SN visited Patient 3’s home from 12/20 to 12/25/21. Further review of Patient 3’s clinical record revealed no documented evidence showing the reason why the SN missed the visits or if an attempt was made to reschedule the visits on another day. On 6/22/22 at 0924 hours, an interview and concurrent clinical record review was conducted with the QM. The QM verified the findings. 9. Review of Patient 5’s clinical record was initiated on 6/16/22. The clinical record showed the SOC was 12/22/20. The patient was certified for home health services during the certification periods from 2/20/21 to 4/20/21 and 4/21/21 to 6/19/21. The POC, for the certification periods from 2/20/21 to 4/20/21 and 4/21/21 to 6/19/21, showed to assess all vital signs, body systems, and to report signs/symptoms necessitating medical attention to the physician. Review of the Skilled Nurse Visit Notes dated 2/22 and 4/12/21, showed no documented evidence the SN had assessed the patient’s integumentary system. Review of the OASIS Nurse Recertification form dated 4/19/21, showed no documented evidence the SN had assessed the patient’s blood pressure. On 6/22/22 at 0945 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding. 10a. Review of Patient 7's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 2/10/22. The patient was certified for home health services during the certification periods from 2/10/22 to 4/10/22 and 4/11/22 to 6/9/22. The POC, for the certification periods from 2/10/22 to 4/10/22 and 4/11/22 to 6/9/22, showed for the SN to photograph and measure the wounds weekly. Review of the Skilled Nurse Visit Notes showed the SN did not consistently assess, measure, or photograph Patient 7’s wounds. For example, on 2/23/22, the SN assessed the patient’s wounds to the right second toe and right fifth toe; however, there was no documented evidence showing the SN had measured the wounds. In addition, there was no documented evidence showing the photographs of the wounds were taken. b. The POC, for the certification period from 2/10/22 to 4/10/22, cited SN visits 1W1, 3W5, then 3W3; however, the SN did not visit the patient’s home as per the POC. For example, the SN only visited the patient’s home two times instead of three for the week of 2/20 to 2/26/22. c. The POC, for the certification period from 4/11/22 to 6/9/22, cited SN visits 3W9; however, the SN did not visit the patient’s home as per the POC. For example, the SN only visited the patient’s home two times instead of three for the week of 4/17 to 4/23/22. Further review of Patient 7’s clinical record revealed no documented evidence showing the reason why the SN missed a visit or if an attempt was made to reschedule the visit on another day to meet the frequency schedule as per the POC. On 6/22/22 at 1040 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the findings. 11. Review of Patient 8's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 11/8/21. The patient was certified for home health services during the certification periods from 3/8/22 to 5/6/22 and 5/7/22 to 7/5/22. The POC, for the certification periods from 3/8/22 to 5/6/22 and 5/7/22 to 7/5/22, showed to assess and perform pulse oximetry checks each visit and PRN for cardiopulmonary symptoms. Review of the OASIS Nurse Recertification forms dated 3/8/22 and 5/3/22, showed no documented evidence the SN had assessed the patient’s oxygen saturation level. In addition, review of the Skilled Nurse Visit Notes, showed the SN did not assess the patient’s oxygen saturation level consistently. For example, on 3/15/22, there was no documented evidence showing the patient’s oxygen saturation. On 6/22/22 at 1007 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding. 12. Review of Patient 9's clinical record was initiated on 6/21/22. The clinical record showed the SOC was 3/23/21. The patient was certified for home health services during the certification period from 3/18/22 to 5/16/22. The POC, for the certification period from 3/18/22 to 5/16/22, cited SN visits 2M3. Review of Patient 9’s clinical record showed the SN only visited the patient’s home on 4/28/22 for the month of April. Further review of Patient 9’s clinical record revealed no documented evidence showing the reason why the SN missed a visit or if an attempt was made to reschedule the visit on another day during the month of April. On 6/22/22 at 1021 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the findings. Review of the agency's P&P titled Missed Visit Notes (undated), showed if a visit or visits are unable to be made as ordered by the end of the week (Saturday)- a Missed Visit Note is to be completed for each visit missed. In addition, every attempt should be made to reschedule a visit within the same Medicare week. 1. Review of Patient 4's closed clinical record was initiated on 6/16/22. The closed clinical record showed the SOC was 2/28/21. The patient was certified for home health services during the certification period from 6/28/22 to 8/26/22. The POC, for the certification period from 6/28 to 8/26/22, showed the SN to change indwelling holey catheter every 21 to 30 days and PRN leaking with 18 French catheter, and instill with 10 cc of sterile water. Review of the SN Visit Notes dated 7/12 and 8/11/22, showed the catheter was changed with a 16 French Foley Catheter. On 6/16/22 at 0900 hours, an interview and concurrent clinical record review was conducted with the VPCO. The VPCO was informed and acknowledged the finding. 2. Review of Patient 1's closed clinical record was initiated on 6/15/22. The closed clinical record showed the SOC was 5/20/21. The patient was certified for home health services during the certification period from 5/20/21 to 7/18/21. The POC, for the certification period from 5/20 to 7/18/21, showed the nutritional requirements included heart healthy, low sodium, and regular diet. Review of the SN Visit Notes dated 5/26, 5/28, 5/31, 6/2, 6/4, and 6/7/22 showed Patient 1's was assessed to be on a NAS (no added salt) diet. On 6/22/22 at 1017 hours, an interview and concurrent closed clinical record review was conducted with the VPCO. The VPCO was informed and acknowledged the finding. 3. Review of Patient 6’s clinical record showed the SOC was 10/15/21. The clinical record showed the patient received home health services during the certification period from 4/13/22 to 6/11/22. The POC, for the certification period from 4/13/22 to 6/11/22, showed the following interventions for wound care: - Assess/ perform/ instruct patient/ PCG pn measure tp prevent skin breakdown, including proper positioning techniques, frequent position changes, hygiene, skin inspection, skin care, increase protein in diet. - Assess/ instruct wound care for stage 4 pressure injury to the sacrum, with treatment to cleanse the wound with normal saline or wound cleanser, apply collagen powder, and covered with bordered foam 2x a week or PRN for loss of integrity. and - Wound nurse to consult and collaborate with RN Case Manager and physician. Review of the SN Visit Note dated 5/11/22, showed Patient 6 was noted with a new open blister on right AKA. Review of the SN Visit Note dated 5/18/22, showed Patient 6's Right distal stump was noted as a stage 4 pressure injury. Further review of the clinical record showed a new wound treatment was implemented, however, there were no competency of the patient/ PCG for wound care. Review of Patient 6's physician's orders dated 5/18/22, showed to assess/ perform/ instruct wound care to the right distal stump, stage 4 medical device related pressure injury. The treatment included to cleanse with wound cleanser, apply collagen powder to base, cover with bordered foam, three times a week to be performed by the skilled nurse/ PCG/ patient. Patient/ PCG to perform wound care once competency demonstrated. Review of the SN Visit Notes dated 5/23, 5/25, 5/30. and 6/1/22, showed the SN provided wound care to the right stump stage 4 pressure injury twice weekly. However, the clinical records failed to show the patient/ PCG was assessed for wound care competency. Further review of the clinical records did not show the SN provided wound care three times a week, per physician's order. On 6/2/22, at 1152, an interview and concurrent clinical record review was conducted with the VPCO. The VPCO was informed and acknowledged the finding. 4. Review of Patient 11's clinical record was initiated on 6/15/22. The clinical record showed the SOC was 5/20/22. The clinical record showed the patient received home health services during the certification period from 5/20/22 to 7/18/22. Review of the patient's POC for the certification period from 5/20/22 to 7/18/22, showed RN/ LPN visit frequency of 1 visit a week for five weeks effective on 5/20/22. Review of the SN Missed Visit Notes dated 5/25/22, showed no SN visit was done. Further review of the clinical record, failed to show another attempt to schedule an SN visit was made that week. On 6/22/22 at 0934 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant stated there were suppose to be another attempt to make an SN visit. The Clinical Manager Assistant was informed and acknowledged the finding. 5. Review of Patient 16's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 1/28/22. The clinical record showed the patient received home health services during the certification period from 1/28/22 to 3/28/22. Review of the patient's POC for the certification period from 1/28/22 to 3/28/22, showed to assess/ perform pulse oximetry each visit and PRN cardio/ pulmonary symptoms. Report oxygenation saturation less than 90% to physician. Review of the SOC OASIS dated 1/28/22, showed the oxygen saturation was noted at 86%. Further review of the clinical record failed to show the physician was notified of the oxygen saturation. Review of the SN Visit notes dated 2/24 and 3/10/22, failed to show documentation the oxygen saturation was assessed. On 6/22/22 at 0934 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant was informed and acknowledged the finding. 6. Review of Patient 10's clinical record was initiated on 6/21/22. The clinical record showed the SOC was 9/11/21. The patient was certified for home health services during the certification period from 9/11/21 to 11/9/21. Review of the POC for certification period 9/11/21 to 11/9/21 showed to notify the physician of BP Systolic greater than 180 or less than 90; Diastolic BP greater than 90 or less than 60; Heart rate greater than 100 or less than 60; Temperature greater than 100.4 degrees Fahrenheit. Review of the SN Visit Note dated showed the following assessments: - On 9/17/21, the pulse was 50; - On 9/21/21, the pulse was 58; - On 9/29/21, the pulse was 56; - On 10/5/21, the pulse was 50; and - On 10/19/21, the pulse was 107. However, further review of the clinical records failed to show the physician was notified of the pulse rate. On 6/22/22 at 1055 hours, the Clinical Manager Assistant was informed and acknowledged the findings. 7a. Review of Patient 12’s clinical record was initiated on 6/20/22. The clinical record showed the SOC was 3/4/22. The patient was certified for home health services during the certification period from 3/4/22 to 5/2/22. The POC, for the certification period from 3/4/22 to 5/2/22 , showed Patient 12 had a pressure injury to the coccyx. The POC showed treatment per Wound Care Specialist once evaluation done. Further review of the POC and clinical record failed to show the specific treatment and frequency for the pressure injury. However, further review of the clinical record failed to show the patient was seen by the wound care specialist, as ordered on the POC. On 6/22/22 at 1102 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant verified the finding. b. The POC, for the certification periods from 3/4/22 to 5/2/22 and 5/3/22 to 7/1/22, showed the SN to change Patient 12's Foley catheter every two weeks, and PRN leaking with a 18 French 10 cc balloon, instill 10 cc sterile water and assess/ perform/ instruct patient/ PCG Foley catheter irrigation PRN with saline. Further review of the clinical record failed to indicate the indication for catheter irrigation. Review of the SOC OASIS dated 3/4/22, noted Patient 12 with a 18 French Foley catheter. Review of the SN Visit Notes date 3/11, 3/14, 3/17, 3/21, 3/24, 3/31, 5/5, 5/12, 5/9, and 5/26/22 noted the patient to have a 16 French Foley catheter. Further review of the clinical records failed to indicate the correct Foley catheter size or the the correct 10 cc sterile water instillation per POC. On 6/22/22 at 1102 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant verified the finding.

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 professionals prepared accurate clinical notes for eight of 17 sampled patients (Patients 2, 3, 7, 10, 11, 12, 16, and 17), creating the increased risk of substandard healthcare outcomes to these patients. 5. Review of Patient 11's clinical record was initiated on 6/15/22. The clinical record showed the SOC was 5/20/22. The patient was certified for home health services during the certification period from 5/20/22 to 7/18/22. Review of the SOC OASIS dated 5/20/22, noted Patient 11 to have a surgical wound to the left cranium, and a surgical wound to the right cranium. Review of the POC for certification period 5/20/22 to 7/18/22, showed an SN intervention for the left cranium surgical wound to leave open to air, with no treatment required. Further review of the clinical record, failed to show an intervention addressing Patient 11's right cranial surgical wound. On 6/22/22 at 0934 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant was informed and acknowledged the finding. 6a. Review of Patient 16's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 1/28/22. The patient was certified for home health services during the certification periods from 1/28/22 to 3/28/22 and 5/28/22 to 7/26/22. Review of the POC for certification period 5/28/22 to 7/26/22, showed the following: - Assessment of all vital signs and body systems and report signs/ symptoms necessitating medical attention to physician; and - Assess/ perform pulse oximetry each visit and PRN for cardio/ pulmonary symptoms and report oxygen saturation less than 90% to the physician. Review of the SN Visit Note dated 6/2/22, showed the patient was assessed to have a temperature of 20 degrees Fahrenheit. In addition, the oxygen saturation was left blank. b. Review of the POC for certification period 5/28/22 to 7/26/22, showed to assess/ perform/ instruct patient/ caregiver neurovascular and circulatory checks to four extremities. Review of the SN Visit Notes dated 6/2 and 6/16/22 showed the SN's conducted a circulatory checks to two extremities, instead of four, per POC. On 6/22/22 at 0954, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant was informed and acknowledged the findings. 7. Review of Patient 10's clinical record was initiated on 6/21/22. The clinical record showed the SOC was 9/11/21. The patient was certified for home health services during the certification periods from 9/11/21 to 11/9/21. Review of the POC for certification period 9/11/21 to 11/9/21 showed the following interventions including: - Assess/ perform pulse oximetry each visit and PRN for cardio/pulmonary symptoms and report oxygen saturation less than 90% to the physician - Notify the physician of BP Systolic greater than 180 or less than 90; Diastolic BP greater than 90 or less than 60; Heart rate greater than 100 or less than 60; Temperature greater than 100.4 degrees Fahrenheit. - Assess/ perform/ instruct patient/ caregiver drain care. However, the intervention failed to indicate the type of drain, the frequency of care, and care instructions. - Sn to change Foley catheter every four weeks, and PRN leaking with 16 French cc balloon and assess/ perform/ instruct patient/ PCG Foley irrigation of 60ml of NS PRN. However, further review of the clinical record failed to indicate when the Foley irrigation was to be done. Review of the SN Visit Note dated 9/17, 9/21, 9/29, 10/19, 10/21, 11/2, showed the SN performed irrigation of the Foley catheter with 60ml NS. However, further review of the clinical record, failed to indicate the reason for the irrigation. Review of the SN Visit Note dated 11/2/22, failed to show documentation the patient's pulse oximetry was assessed as per the POC. On 6/22/22 at 1055 hours, the Clinical Manager Assistant was informed and acknowledged the findings. 8a. According to the International Wound Journal, dated 2016, wound measurement is important in monitoring the healing process of chronic wounds and in evaluating the effect of treatment. Review of Patient 12’s clinical record was initiated on 6/20/22. The clinical record showed the SOC was 3/4/22. The patient was certified for home health services during the certification period from 3/4/22 to 5/2/22. The POC, for the certification period from 3/4/22 to 5/2/22 , showed Patient 12 had a pressure injury to the coccyx. The POC showed treatment per Wound Care Specialist once evaluation done. Further review of the POC and clinical record failed to show the specific treatment and frequency for the pressure injury. Review of the SOC OASIS dated 3/4/22, showed the patient had a stage 4 pressure injury to the coccyx. Further review of the SOC OASIS failed to show the wound was measured. Review of the Skilled Nurse Visit Notes dated 3/11, 3/14, and 3/17 showed treatment was provided to the wound on the coccyx. Further review of the SN clinical document showed the SN provided treatment without a physician order. Further review of the patient's clinical record failed to show the wound was measured. Review of the Skilled Nurses Visit Notes dated 4/7, 4/11, 4/14, 5/2/22, failed to show the patient's wound was completely assessed to include, location, type, stage, or measurements. On 6/22/22 at 1102 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant stated the wounds should be measured at least weekly during the dressing change. The Clinical Manager Assistant was informed and acknowledged the finding. b. The POC, for the certification period from 3/4/22 to 5/2/22 , showed the SN to change Patient 12's Foley catheter every two weeks, and PRN leaking with a 18 French 10 cc balloon, instill 10 cc sterile water. Review of the SOC OASIS dated 3/4/22, noted Patient 12 with a 18 French Foley catheter. Review of the SN Visit Notes date 3/8, 4/18, 4/25, 5/2/22, noted the patient with a Foley catheter. However, further review of the clinical records failed to indicate the Foley catheter size or date of catheter last changed. On 6/22/22 at 1102 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager Assistant. The Clinical Manager Assistant verified the finding. 1. Review of Patient 2’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 11/19/21. The patient was certified for home health services during the certification periods from 1/18/22 to 3/18/22 and 3/19/22 to 5/17/22. The POC, for the certification periods from 1/18/22 to 3/18/22 and 3/19/22 to 5/17/22, showed Patient 2’s nutritional requirement was heart healthy. However, review of the Skilled Nurse Visit Notes showed the SN was documenting the incorrect diet. For example, on 3/30/22, the SN documented the patient had a regular diet which was inconsistent with the POC. On 6/22/22 at 0904 hours, an interview and concurrent clinical record review was conducted with the QM. The QM verified the finding. 2a. Review of Patient 3’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 10/21/21. The patient was certified for home health services during the certification period from 10/21/21 to 12/19/21. The POC, for the certification period from 10/21/21 to 12/19/21, showed to assess the pressure ulcer/skin tear to the right buttock. Review of the OASIS SOC dated 10/21/21, showed the SN documented the patient had a Stage 2 pressure injury to the coccyx. However, under goals, the SN documented the patient had a wound to the buttocks and under plans for the next visit, the SN documented the SN will assess the patient’s left buttock. In addition, review of the Skilled Nurse Visit Notes showed the SN was inconsistently documenting the correct location of the patient’s wound. For example, on 10/29/21, the notes showed the SN assessed the patient’s Stage 2 pressure injury to the left buttock; however, the photograph taken showed the wound was on the right buttock. b. The POC, for the certification period from 10/21/21 to 12/19/21, showed Patient 3’s nutritional requirement was zero gram sodium. However, review of the Skilled Nurse Visit Notes showed the SN was documenting the incorrect diet. For example, on 11/22/21, the SN documented the patient had a regular diet which was inconsistent with the POC. On 6/22/22 at 0924 hours, an interview and concurrent clinical record review was conducted with the QM. The QM verified the findings. 3. Review of Patient 7's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 2/10/22. The patient was certified for home health services during the certification periods from 2/10/22 to 4/10/22 and 4/11/22 to 6/9/22. The POC, for the certification periods from 2/10/22 to 4/10/22 and 4/11/22 to 6/9/22, showed Patient 7’s nutritional requirement was autoimmune protocol. However, review of the Skilled Nurse Visit Notes showed the SN was documenting the incorrect diet. For example, on 4/13/22, the SN documented the patient had a heart healthy diet which was inconsistent with the POC. On 6/22/22 at 1040 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding. 4. Review of Patient 17’s clinical record was initiated on 6/17/22. The clinical record showed the SOC was 4/1/22. The clinical record showed the patient received home health services during the certification period from 4/1/22 to 5/30/22. The POC, for the certification period from 4/1/22 to 5/30/22, showed to perform and assess the patient’s surgical wound to the left lower extremity. Review of the Skilled Nurse Visit Notes showed the SN was assessing and providing wound treatment for Patient 17; however, the SN was documenting the incorrect location and type of wound. For example, on 4/8/22, the SN documented that she assessed and provided treatment for the right lower extremity skin lesion instead of the left lower extremity surgical wound. On 6/22/22 at 1227 hours, an interview and concurrent clinical record review was conducted with the VPCO. The VPCO was informed of the findings.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the RN provided supervisions to the LVNs to ensure quality care and services were provided for three of 17 sampled patients (Patients 2, 3, and 7). This failure had the potential to place the patients at risk for receiving substandard care and services. Review of the agency's P&P titled Supervision of Clinical Staff dated 5/24/22, showed the LVNs will be supervised by an RN a minimum of 30 days. This supervision and the LVNs care delivery performance will be documented in the context of the care delivery note if a visit was made or in a supervisory note if a visit was not made. 1. Review of Patient 2’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 11/19/21. The patient was certified for home health services during the certification period from 3/19/22 to 5/17/22. The POC, for the certification period from 3/19/22 to 5/17/22, cited SN visits 1W9. Review of the Skilled Nurse Visit Notes showed the LVNs had visited the patient’s home and performed the assessments as per the visit frequency cited in the POC. However, there was no documented evidence the RN provided supervision to the LVNs for the month of April 2022. On 6/22/22 at 0904 hours, an interview and concurrent record review was conducted with the QM. The QM was informed and acknowledged the finding. 2. Review of Patient 7's clinical record was initiated on 6/20/22. The clinical record showed the SOC was 2/10/22. The patient was certified for home health services during the certification period from 4/11/22 to 6/9/22. The POC, for the certification period from 4/11/22 to 6/9/22, cited SN visits 3W9 and 3 PRN visits for dressing malfunction. Review of the Skilled Nurse Visit Notes showed the LVNs had visited the patient’s home and performed the assessments for the month of May However, there was no documented evidence the RN provided supervision to the LVNs during this month. On 6/22/22 at 1040 hours, an interview and concurrent record review was conducted with the QM. The QM was informed and acknowledged the finding. 3. Review of Patient 3’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 10/21/21. The patient was certified for home health services during the certification period from 10/21/21 to 12/19/21. The POC, for the certification period from 10/21/21 to 12/19/21, cited SN visits 1W1, 2W4, then 1W5. Review of the Skilled Nurse Visit Notes showed the LVNs had visited the patient’s home on 11/11, 11/13, 11/15, and 11/22/21. However, there was no documented evidence the RN provided supervision to the LVNs for the month of November 2021. On 6/22/22 at 0924 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide services in accordance with the clinical practice guidelines and accepted professional standards of practice for two of 17 sampled patients (Patients 3 and 8). This created the risk for poor health outcomes for this patient. 1. Review of Patient 3’s clinical record was initiated on 6/15/22. The clinical record showed the SOC was 10/21/21. The patient was certified for home health services during the certification period from 10/21/21 to 12/19/21. The POC, for the certification period from 10/21/21 to 12/19/21, showed SN to assess Patient 3’s buttock wound daily. Review of the Skilled Nurse Visit Notes dated 10/26/21, showed no documented evidence the wound was assessed. There was no documented evidence of the measurement and characteristics of the wound. On 6/22/22 at 0924 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding. 2. Review of Patient 8’s clinical record was initiated on 6/20/22. The clinical record showed the SOC was 11/8/21. The patient was certified for home health services during the certification period from 3/8/22 to 5/6/22. The POC, for the certification period from 3/8/22 to 5/6/22, showed to assess and perform wound care treatment to the left lateral distal leg, right medial distal leg, and right medial malleolus (ankle) daily. Review of the Skilled Nurse Visit Notes showed the SN had performed the wound dressing changes during the SN visits. However, the SN did not consistently document the complete assessment of the wounds. For example, on 3/15/22, there was no documentation of the measurements and characteristics of the wounds. On 6/22/22 at 1007 hours, an interview and concurrent clinical record review was conducted with the QM. The QM was informed and acknowledged the finding.

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 ensure the discharge/transfer summaries for two of 17 sampled patients (Patients 2 and 4) were completed. This failure created the risk of risk of substandard care provided to these patients as their clinical information were not accurate and complete. 2. Review of the P&P titled Discharge/Transfer from Agency dated 5/24/22, showed once home care services have been discontinued, the discharge OASIS will be collected and transmitted in accordance with agency policy. A discharge summary will be completed. The discahrge summary will be sent to the patient's primary care practitioner, or other health care professional responsible for providing care and services to the patient after discharge from the agency, within five business days of the patient's discharge. Review of Patient 2's clinical record was initiated on 6/15/22. The clinical record showed the SOC was 11/19/21. The patient was certified for home health services during the certification period from 3/19/22 to 5/17/22. The POC, for the certification period from 3/19/22 to 5/17/22, cited SN visits 1W9. Review of Patient 2’s clinical record showed the SN last visited the patient on 5/11/22. There was no documented evidence showing the SN visited the patient on the last week of the certification period from 5/15 to 5/17/22. Review of the OASIS Discharge Non-Visit dated 6/2/22, showed the patient was discharged from the agency; however, the form was incomplete and did not include any information regarding the patient’s discharge instructions, condition, and medications at the time of discharge. In addition, there was no documented evidence showing the discharge summary was sent to the physician. On 6/22/22 at 0922 hours, an interview and concurrent clinical record review was conducted with the VPCO. The VPCO stated Patient 2 was discharged from the agency and the home health services were not recertified after 5/17/22. The VPCO verified the patient’s discharge summary was not completed because the nurse who was taking care of the patient left and the agency did not have another SN who knew the patient well enough to complete the discharge summary. 1. Review of Patient 4's closed clinical record was initiated on 6/16/22. The closed clinical record showed the SOC was 2/28/22. The patient was certified for home health services during the certification period from 8/27/21 to 10/25/21. Review of the agency's Transfer Communication note dated 10/21/21, showed Patient 4 was admitted hospice services on 10/18/22. Review of the Discharge OASIS dated 10/17/22, showed the reason for discharge was a transfer to hospice services in the home. Further review of the clinical record, failed to show discharge instructions were provided to the patient, or family/ caregiver. On 6/15/22 at 1330 hours, an interview and concurrent closed clinical record review was conducted with the VPCO. The VPCO added the discharge summary was sent to the physician a month after discharge. The VPCO was informed and acknowledged the above findings.