Every finding on record at Mg Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted at the home health agency’s unapproved new address at 15643 Sherman Way Suite 200B Van Nuys, CA. 91406 from 8/20/24 to 8/23/2024. Old Address: 13758 Victory Blvd. Suite 203 Van Nuys, CA. 91401 New Address: Sherman Way . Suite 200B Van Nuys, CA. 91406 Complaint Number: 109028 Active Patients: 0 Discharge Census: 226 Sample Size - 7 Discharge Home Visits - 3 On 8/20/2024, at 4:40 p.m., the Department called the first Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) related to the HHA failure to ensure to safeguard Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 clinical records from possible loss or unauthorized access. The non-compliance has the potential to result in unauthorized use of patients’ information or loss of clinical records that could result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 receiving wrong treatment, poor patient care, unclear evaluations and treatment plans that increased the risk of these patients to hospitalization and serious injury, harm, and death. On 8/23/2024, at 5:14 p.m., the Department called a second Immediate Jeopardy in the presence of the HHA’s Administrator Designee (ADD, a similarly qualified [qualified as administrator] designee available in the administrator's absence) related to the HHA’s failure to ensure a governing body assumed responsibility for the operations of the HHA, ensure the HHA’s ADM ensured a clinical manager was available during all operating hours, and ensure the agency’s DPCS provided oversight to ensure the clinical records were completed for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7. The non-compliance had the potential to result in disruption of patient care and services for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7, receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024, at 5:30 p.m., the Administrator Designee (AD) told the survey team the agency would be closed (for business) and would no longer be opened. HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team was not able to complete the survey tasks and could not exit (end) the survey. The following conditions of participations were not met: 484.50-Patients Rights 484.105-Organization/administration services 484.110-Clinical Records

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: The Home Health Agency (HHA) failed to ensure to inform four of seven sampled patients (Patients 1, Patient 2, Patient 3, Patient 5 and Patient 7), regarding their being discharged from the HHA services. This deficient practice had the potential to result in Patient 1, Patient 2, Patient 3, Patient 5 and Patient 7's, discharge planning needs to not be identified and addressed.(Refer to G434). The cumulative effect of this systemic practice resulted in the non compliance of the HHA to provide quality of care to the patients which whom they were responsible for ensuring services/care were provided, and to discharge the patients without their knowledge which had the potential to result in the patients goals not being properly met and having their Patient rights violated for Patients 1's, Patient 2's, and Patient 3, Patient 5 and Patient 7.

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: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to inform four of seven sampled patients (Patients 1, Patient 2, Patient 3, Patient 5 and Patient 7), regarding their being discharged from the HHA services. This deficient practice had the potential to result in Patient 1, Patient 2, Patient 3, Patient 5 and Patient 7's, discharge planning needs to not be identified and addressed. a 1). During a review of Patient 1’s record titled, “Patient Profile (comprehensive summary of health related information for an individual patient that includes personal, demographic details, contact information and a thorough record of clinical data), Patient 1 Profile indicated a Start Of Care (SOC) of 5/15/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar) and a secondary diagnosis of primary osteoarthritis (causes joint [the connection between bones or other hard structures in the body] pain, swelling, and tenderness) of right shoulder. During an interview on 8/21/2024 at 11:15 a.m., in Patient 1’s home, Patient 1 stated he has been a patient with Agency 3 (A3) for four to five years, on and off, and was still being seen and visited by a Skilled Nurse (SN) from A3. Patient 1 stated the last visit he received from a SN was last week, Patient 1 could not remember the day, and is due for another SN visit this week. Patient 1 stated he was not aware that he has been discharged from A3 and was not provided any discharge summary. Patient further stated he has only known A3 and has been under services care with A3, stated he does not know or heard about Agency 1 (A1) and has not been under A1 services. During a review of Patient 1’s Physician Order, dated 7/13/2024, the Physician order indicated, “Discharge patient from MG Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 1’s physician name, with a digital signature by Registered Nurse 1 (RN 1) with date of 7/13/2024 and a hand a written signature under “Physician signature” with date of 7/17/24. During a review of Patient 1’s Discharge (D/C) Summary, dated 7/13/2024, the D/C Summary indicated, date of completion of 7/13/2024 and discharge date of 7/12/2024. The D/C Summary indicated reason was “goals met / max potential reached”. The D/C Summary, under the section “Goals summary / outcomes”, indicated a check mark next to “goals met”,” condition improved”, “stabilized”, and “deterioration of functional status”. The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “yes” “patient” “caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “yes” “patient” and “caregiver”. The D/C summary was digitally signed by RN 1 with date of 7/13/2024 and under physician name, Patient 1’s physician name was noted. During a review of Patient 1’s Oasis Discharge, dated 7/13/2024, the Oasis Discharge indicated a visit date of 7/13/2024. The Oasis Discharge further indicated incomplete documentation under “LVN/LPN Supervisory Note” and “Aide supervisory Visit." The Oasis Discharge indicated a digital signature by RN 1 with date of 7/13/2024. b 2). During a review of Patient 2’s record titled “Patient Profile” the Profile indicated a SOC effective date of 5/8/2024, with a primary diagnosis of bilateral primary osteoarthritis of the knee and a secondary diagnosis of polyosteoarthritis (having arthritis [inflammation of the joint] that affects five or more joints at the same time). During a phone interview on 8/21/2024 at 2 pm with Patient 2, Patient 2 stated she is a new patient to A3, and just started one month ago. Patient 1 stated her last visit from a SN from A3 was on Monday and has another visit to be scheduled for this week. Patient 1 further stated she was not made aware of being discharged from A3, and did not receive discharge forms. Patient 2 stated she did not know who A1 was and did not sign up to receive services under A1. Patient 2 continued to state she just started services with A3, “the one with the gold folder," and is currently being visited by SN from A3. During a review of Patient 2’s Physician Order, dated 7/3/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 2’s physician name, with a digital signature by DPCS with date of 7/3/2024 and a hand a written signature under “Physician signature” with date of 7/8/24. During a review of Patient 2’s Discharge (D/C) Summary, dated 7/6/2024, the D/C Summary indicated, date of completion of 7/6/2024 and a discharge date of 7/6/2024. The D/C Summary reason was “Goals met /max potential reached." The D/C Summary, under the section “Goals summary/outcomes” indicated a check mark next to “Goals met” condition improved” "Max potential reached," “stabilized”, “improved independence” and “improved functional status.” The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” Patient” and “Caregiver." The D/C summary was digitally signed by RN 1 with date of 7/6/2024 and under the physician name, Patient 2’s physician name was noted. During a review of Patient 2’s Oasis Discharge, dated 7/6/2024, the Oasis Discharge indicated a visit date of 7/6/2024. The Oasis Discharge further indicated incomplete documentation under “LVN/LPN Supervisory Note” and “Aide supervisory Visit." The Oasis Discharge indicated a digital signature by DPCS with date of 7/6/2024. c 3). During a review of Patient 3’s record titled, “Patient Profile," the profile indicated a SOC of 3/16/2024, with a primary diagnosis of bilateral primary osteoarthritis of first carpometacarpal joints (base of the thumb that connects the thumb to the wrist) and a secondary diagnosis of bilateral primary osteoarthritis of knee. During a phone interview on 8/21/2024 at 3 pm with Patient 3, Patient 3 stated she did not know who A3 was. Patient 3 stated she was unaware of being under services with A3. Patient stated she has not had a SN or therapist come to her home or call her within the last two months. Patient 3 further stated she has had a live in caregiver who takes care of her 24/7. Patient 3 stated the last time she had a SN and therapist visit her was when she had knee surgery in the year 2023 and was at home for recovery. Patient 3 stated she did not remember the name of the agency providing her services and did not remember the date of the last visit she had by SN or therapy. When Patient 3 was asked if she knew A1 or was under any services with A1 at any time, Patient 3 stated she does not remember A1's name and was not sure if A1 or A3 had been providing her with at home services after her surgeries. During a review of Patient 3’s Physician Order, dated 7/13/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 3’s physician name, with a digital signature by RN 1 with date of 7/13/2024 and a hand a written signature under “Physician signature” with date of 7/18/24. During a review of Patient 3’s Discharge (D/C) Summary, dated 7/13/2024, the D/C Summary indicated, a date of completion of 7/13/2024 and a discharge date of 7/12/2024. The D/C Summary indicated the reason for the discharge was “Goals met/max potential reached.” The D/C Summary, under the section “Goals summary/outcomes,” indicated a check mark next to “Goals met,” "Condition improved”, “Stabilized”, “improved independence," “Improved functional status” and “Improved knowledge of self-care management." The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “Caregiver." The D/C summary was digitally signed by RN 1 with date of 7/13/2024 and under physician name, Patient 3’s physician name was noted. During a review of Patient 3’s Oasis Discharge, dated 7/13/2024, the Oasis Discharge indicated a visit date of 7/13/2024. The Oasis Discharge further indicated incomplete documentation under “LVN/LPN Supervisory Note” and “Aide supervisory Visit." The Oasis Discharge indicated a digital signature by RN 1 with date of 7/13/2024. 4). During a review of Patient 5’s record titled “Patient Profile," the Patient Profile indicated a SOC date of 7/23/2024, with a diagnoses of arthritis multiple sites, and spondylosis (the development of age-related arthritis that affects the spine). During a review of Patient 5’s Physician Order, dated 7/31/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with a reason for discharge as “Patients goals have been met." The physician order indicated Patient 5’s physician name, with a digital signature by RN 1 with date of 7/31/2024 and a hand a written signature under “Physician signature” with a date of 8/2/24. During a telephone interview with Patient 5 on 8/2/2024, at 3:30 p.m., Patient 5 stated that she has been with Agency 3 for over a year and receives weekly nurse visits from A 3’s nurse. Patient 5 stated that A 3/s LVN came last week, and she is waiting for her to contact her for this weeks visit. Patient 5 stated she is still a patient of A3 and that no one discussed with her anything about her being discharged. During a review of Patient 5’s Physician Order, dated 7/31/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 5’s physician name, with a digital signature by RN 1 with date of 7/31/2024 and a hand a written signature under “Physician signature” with date of 8/2/24. During a review of Patient 5’s Discharge (D/C) Summary, dated 7/31/2024, the D/C Summary indicated the date of completion on 7/31/2024 and a discharge date of 7/30/2024. The D/C Summary indicated the reason for the discharge was “Goals met/max potential reached." The D/C Summary, under the section “Goals summary/outcomes” indicated a check mark next to “Goals met” "Condition improved” “Stabilized” and “improved independence” “improved functional status," and “improved knowledge of self-care management." The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “Caregiver." The D/C summary was digitally signed by RN 1 with a date of 7/31/2024 and under physician's name, Patient 5’s physician's name was noted. e 5). During a review of Patient 7’s record titled, “Patient Profile”, the Profile indicated a SOC date of 3/13/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). During a review of Patient 7’s Physician Order, dated 7/6/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 7’s physician name, with a digital signature by RN 1 with date of 7/6/2024 and a hand a written signature under “Physician signature” with date of 7/12/24. During a review of Patient 7’s Discharge (D/C) Summary, dated 7/6/2024, the D/C Summary indicated a date of completion of 7/6/2024 and discharge date of 7/5/2024. The D/C Summary indicated the discharge reason was “Goals met/max potential reached." The D/C Summary, under the section “Goals summary/outcomes” indicated a check mark next to “Goals met”,” condition improved," “Stabilized," “Improved independence," “Improved functional status," and “Improved knowledge of self-care management." The D/C Summary further indicated “Discharge instructions Provided?” with a check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “yes” “Patient” and “Caregiver. ”The D/C summary was digitally signed by RN 1 with date of 7/6/2024 and under physician name, Patient 7’s physician name was noted. During a telephone interview with the RN 1, in A3 on 8/23/2024, at 3:30 pm, RN 1 stated that she has not worked for A3 and A2 since June/July of this year and that she was never the DPCSD for the home health agencies, RN 1 stated she was the Nurse who only did start of care visits and that the HHA did not have a DPCSD only a DPCS. During a Review of the HHA’s Policy and Procedure (P&P) titled, “Discharge Planning, Transfer, And Continuing Care Needs” (undated), the P&P indicated “Discharge 2. The staff member should prepare the patient for discharge by instructing the patient/caregiver to perform necessary care or should work toward making alternate plans for continuing care when further health care is needed. …5. Patients are informed prior to discharge of plans for discharge and the reason for discharge.”

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to complete a safe discharge by failing to: Ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) included that the discharge summary was completed at the time of discharge. Inform the patient of being discharged from services for seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6 and Patient 7). This failure resulted in an incomplete assessment that accurately reflected the patients' current health status, anticipated improvement of the health status, and patient care goals to be met at discharge. a1. During a review of Patient 1’s record titled, “Patient Profile (comprehensive summary of health related information for an individual patient that includes personal, demographic details, contact information and a thorough record of clinical data), the Profile indicated a Start Of Care (SOC) effective date of 5/15/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar) and a secondary diagnosis of primary osteoarthritis (causes joint [the connection between bones or other hard structures in the body] pain, swelling, and tenderness) of the right shoulder. During an interview on 8/21/2024 at 11:15 a.m., in Patient 1’s home, Patient 1 stated he has been a patient with Agency 3 (A3) for four to five years, on and off, and was still being seen and visited by a Skilled Nurse (SN) from A3. Patient 1 stated the last visit he received from a SN was last week, Patient 1 could not remember the day, and is due for another SN visit this week. Patient 1 stated he was not aware that he has been discharged from A3 and was not provided any discharge summary. Patient 1 further stated he has only known A3 and has been under services care with A3, stated he does not know or heard about Agency 1 (A1) and has not been under A1 services. During a review of Patient 1’s Physician Order, dated 7/13/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with the reason for discharge as “Patients goals have been met.” The physician order indicated Patient 1’s physician name, with a digital signature by Registered Nurse 1 (RN 1) with date of 7/13/2024 and a hand a written signature under “Physician signature” with date of 7/17/24. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 1’s Electronic Health Record (EHR), it was noted that Patient 1’s Physician Order for Discharge dated 7/13/2024, the task was created on August 20, 2024, and returned with physician signature on August 21, 2024. During a review of Patient 1’s Discharge (D/C) Summary, dated 7/13/2024, the D/C Summary indicated, date of completion of 7/13/2024 and discharge date of 7/12/2024. The D/C Summary indicated the reason was “Goals met/max potential reached." The D/C Summary, under the section “Goals summary/outcomes." indicated a check mark next to “Goals met”, ” condition improved”, “Stabilized”, and “Deterioration of functional status.” The D/C Summary further indicated “Discharge instructions Provided?” with a check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “Caregiver." The D/C summary was digitally signed by RN 1 with a date of 7/13/2024 and under physician name, Patient 1’s physician name was noted. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 1’s Electronic Health Record (EHR), it was noted that Patient 1’s D/C Summary dated 7/13/2024, the task was created on date of August 21, 2024 and completed on date of August 21, 2024. During a review of Patient 1’s Oasis Discharge, dated 7/13/2024, the Oasis Discharge indicated a visit date of 7/13/2024. The Oasis Discharge further indicated incomplete documentation under “LVN/LPN Supervisory Note” and “Aide supervisory Visit." The Oasis Discharge indicated a digital signature by RN 1 with date of 7/13/2024. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 1’s Electronic Health Record (EHR), it was noted that Patient 1’s Oasis Discharge dated 7/13/2024, the task was created on date of July 10, 2024, and then “Reopened” on date of August 20, 2024, signed and “Exported” on date of August 21, 2024. b2. During a review of Patient 2’s record titled “Patient Profile”, Patient 2 Profile indicated a SOC of 5/8/2024, with a primary diagnosis of bilateral primary osteoarthritis of knee and a secondary diagnosis of polyosteoarthritis (having arthritis [inflammation of the joint] that affects five or more joints at the same time). During a phone interview on 8/21/2024 at 2 pm with Patient 2, Patient 2 stated she is a new patient to A3, and just started one month ago. Patient 2 stated her last visit from a SN from A3 was on Monday and she has another visit to be scheduled for this week. Patient 1 further stated she was not made aware of being discharged from A3, and did not receive discharge forms. Patient 2 stated she did not know who A1 was and did not sign up to receive services under A1. Patient 2 continued to state she just started services with A3, “The one with the gold folder” and is currently being visited by SN from A3. During a review of Patient 2’s Physician Order, dated 7/3/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 2’s physician name, with a digital signature by DPCS with date of 7/3/2024 and a hand a written signature under “Physician signature” with date of 7/8/24. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 2’s Electronic Health Record (EHR), it was noted that Patient 2’s Physician Order for Discharge dated 7/3/2024, the task was created on August 20, 2024, and returned with physician signature on August 21, 2024. During a review of Patient 2’s Discharge (D/C) Summary, dated 7/6/2024, the D/C Summary indicated, date of completion of 7/6/2024 and discharge date of 7/6/2024. The D/C Summary indicated the reason for discharge was “Goals met/max potential reached." The D/C Summary, under the section “Goals summary/outcomes," indicated a check mark next to “Goals met,” condition improved," “Max potential reached," “stabilized” “improved independence” and “improved functional status”. The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “Caregiver." The D/C summary was digitally signed by RN 1 with date of 7/6/2024 and under physician name, Patient 2’s physician name was noted. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 2’s Electronic Health Record (EHR), it was noted that Patient 2’s D/C Summary dated 7/6/2024, the task was created on August 21, 2024, and completed on date of August 21, 2024. During a review of Patient 2’s Oasis Discharge, dated 7/6/2024, the Oasis Discharge indicated a visit date of 7/6/2024. The Oasis Discharge further indicated incomplete documentation under “LVN/LPN Supervisory Note” and “Aide supervisory Visit." The Oasis Discharge indicated a digital signature by DPCS with date of 7/6/2024. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 2’s Electronic Health Record (EHR), it was noted that Patient 2’s Oasis Discharge dated 7/6/2024, the task was created on June 5, 2024 and then “Reopened” on August 20, 2024 and August 21, 2024, and signed on August 22, 2024 by the Director of Patient Care Services (DPCS). c3. During a review of Patient 3’s record titled, “Patient Profile” the Profile indicated a SOC of 3/16/2024, with a primary diagnosis of bilateral primary osteoarthritis of first carpometacarpal joints (base of the thumb that connects the thumb to the wrist) and a secondary diagnosis of bilateral primary osteoarthritis of knee. During a phone interview on 8/21/2024 at 3 pm with Patient 3, Patient 3 stated she did not know who A3 was. Patient stated she was unaware of being under services with A3. Patient 3 stated she has not had a SN or therapist come to her home or call her within the last two months. Patient further stated she has had a live in caregiver who takes care of her 24/7. Patient 3 stated the last time she had a SN and therapist visit her was when she had knee surgery in the year 2023 and was at home for recovery. Patient 3 stated she did not remember the name of the agency providing her services and did not remember the date of the last visit she had by SN or therapy. When Patient 3 was asked if she knew A1 or was under any services with A1 at any time, Patient 3 stated she does not remember A1 name and was not sure if A1 or A3 had been providing her with at home services after her surgeries. During a review of Patient 3’s Physician Order, dated 7/13/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 3’s physician name, with a digital signature by RN 1 with date of 7/13/2024 and a hand a written signature under “Physician signature” with date of 7/18/24. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 3’s Electronic Health Record (EHR), it was noted that Patient 3’s Physician Order for Discharge dated 7/13/2024, the task was created on August 20, 2024, and returned with physician signature on August 21, 2024. During a review of Patient 3’s Discharge (D/C) Summary, dated 7/13/2024, the D/C Summary indicated, date of completion of 7/13/2024 and discharge date of 7/12/2024. The D/C Summary indicated reason was “goals met / max potential reached”. The D/C Summary, under the section “Goals summary /outcomes”, indicated a check mark next to “goals met”,” condition improved”, “stabilized”, “improved independence”, “improved functional status”, and “improved knowledge of self-care management”. The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “yes” “patient” “caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “caregiver”. The D/C summary was digitally signed by RN 1 with date of 7/13/2024 and under physician name, Patient 3’s physician name was noted. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 3’s Electronic Health Record (EHR), it was noted that Patient 3’s D/C Summary dated 7/13/2024, the task was created on August 21, 2024, and completed on date of August 21, 2024. During a review of Patient 3’s Oasis Discharge, dated 7/13/2024, the Oasis Discharge indicated a visit date of 7/13/2024. The Oasis Discharge further indicated incomplete documentation under “LVN/LPN Supervisory Note” and “Aide supervisory Visit." The Oasis Discharge indicated a digital signature by RN 1 with date of 7/13/2024. During an audit (a systematic examination of patient records to assess the quality, accuracy, and completeness of documentation and care delivery) of Patient 3’s Electronic Health Record (EHR), it was noted that Patient 3’s Oasis Discharge dated 7/13/2024, the task was created on July 10, 2024, and then “Reopened” and signed on date of August 20, 2024, and exported on August 21, 2024. d4. During a review of Patient 4’s record titled, “Patient Profile”, Patient 4 Profile indicated a SOC date of 3/14/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hereditary and idiopathic neuropathies (are both nervous system disorders that can affect nerve functions) and difficulty walking. Continued review of Patient 4’s “Patient Profile” indicated that Patient 4 resides in another city in CA., and there was no contact number on Patient 4’s Medical Forms titled, “Patient Information. During a review of Patient 4’s Physician Order, dated 7/11/2024, the Physician order indicated, “Discharge patient from MG Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 4’s physician name, with a digital signature by RN 1 with date of 7/11/2024 and a hand a written signature under “Physician signature” with date of 7/16/24. During a review of Patient 4’s Discharge (D/C) Summary, dated 7/11/2024, the D/C Summary indicated, date of completion of 7/11/2024 and discharge date of 7/11/2024. The D/C Summary indicated the reason for discharge was “Goals met/max potential reached." The D/C Summary, under the section “Goals summary/outcomes” indicated a check mark next to “Goals met”,” Condition improved”, “stabilized”, “improved independence”, “improved functional status”, and “improved knowledge of self-care management." The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “Caregiver." The D/C summary was digitally signed by RN 1 with date of 7/11/2024 and under physician name, Patient 4’s physician name was noted. e5. During a review of Patient 5’s record titled “Patient Profile”, the Patient Profile indicated a SOC date of 7/23/2024, with diagnoses of arthritis multiple sites, and spondylosis (the development of age-related arthritis that affects the spine). During a review of Patient 5’s Physician Order, dated 7/31/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician's order indicated Patient 5’s physician name, with a digital signature by RN 1 with date of 7/31/2024 and a hand a written signature under “Physician signature” with date of 8/2/24. During a telephone interview with Patient 5 on 8/2/2024, at 3:30 p.m., Patient 5 stated that she has been with Agency 3(A3) for over a year and receives weekly nurse visits from A 3’s nurse. Patient 5 stated that A 3/s LVN came last week, and she is waiting for her to contact her for this weeks visit. Patient 5 stated she is still a patient of A3 and that no one discussed with her anything about her being discharged. During a review of Patient 5’s Physician Order, dated 7/31/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 5’s physician name, with a digital signature by RN 1 with date of 7/31/2024 and a hand a written signature under “Physician signature” with date of 8/2/24. During a review of Patient 5’s Discharge (D/C) Summary, dated 7/31/2024, the D/C Summary indicated, date of completion of 7/31/2024 and discharge date of 7/30/2024. The D/C Summary indicated reason for the discharge was “Goals met/max potential reached.” The D/C Summary, under the section “Goals summary/outcomes indicated a check mark next to “Goals met”, ”Condition improved”, “Stabilized”, “Improved independence”, “Improved functional status”, and “improved knowledge of self-care management.” The D/C Summary further indicated “Discharge instructions Provided?” with a check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “Caregiver.” The D/C summary was digitally signed by RN 1 with date of 7/31/2024 and under physician name, Patient 5’s physician name was noted. f.6. During a review of Patient 6’s record titled, “Patient Profile”, the “Patient Profile” indicated a start of care date of 8/6/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hypertensive heart disease without heart failure (a category of heart disease that occurs when high blood pressure over a long period of time causes heart problems). During a review of Patient 6’s Physician Order, dated 7/27/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 6’s physician name, with a digital signature by RN 1 with date of 7/27/2024. There was no physicians signature or date on Patient 6’s physician discharge form. During a review of Patient 6’s Discharge (D/C) Summary, dated 7/27/2024, the D/C Summary indicated, date of completion of 7/27/2024 and discharge date of 7/27/2024. The D/C Summary indicated reason was “goals met / max potential reached." The D/C Summary, under the section “Goals summary/outcomes” indicated a check mark next to “Goals met”,” condition improved”, “stabilized”, “improved independence”, “improved functional status”, and “improved knowledge of self-care management." The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “Yes” “Patient” and “Caregiver”. The D/C summary was digitally signed by RN 1 with date of 7/27/2024 and under physician name, Patient 6’s physician name was noted. g7. During a review of Patient 7’s record titled, “Patient Profile”, Patient 7 Profile indicated a SOC date of 3/13/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). During a review of Patient 7’s Physician Order, dated 7/6/2024, the Physician order indicated, “Discharge patient from A3 Home health INC services” with reason for discharge as “Patients goals have been met.” The physician order indicated Patient 4’s physician name, with a digital signature by RN 1 with date of 7/6/2024 and a hand a written signature under “Physician signature” with date of 7/12/24. During a review of Patient 7’s Discharge (D/C) Summary, dated 7/6/2024, the D/C Summary indicated, date of completion of 7/6/2024 and discharge date of 7/5/2024. The D/C Summary indicated reason was “goals met / max potential reached." The D/C Summary, under the section “Goals summary/outcomes”, indicated a check mark next to “Goals met” "Condition improved”, “stabilized”, “improved independence”, “improved functional status”, and “improved knowledge of self-care management." The D/C Summary further indicated “Discharge instructions Provided?” with check mark next to “Yes” “Patient” “Caregiver” and indicated “Informed of discharge prior to discharge date, per agency policy & timeline?” with a check mark next to “yes” “patient” and “caregiver." The D/C summary was digitally signed by RN 1 with date of 7/6/2024 and under physician name, Patient 7’s physician name was noted. During a telephone interview with the RN 1, in A3 on 8/23/2024, at 3:30 pm, The RN 1 stated that she has not worked for A3 and A2 since June/July of this year and that she was never the DPCSD for the home health agencies. RN 1 stated she was the Nurse who only did start of care visits and that the HHA did not have a DPCSD only a DPCS. During a Review of the HHA’s Policy and Procedure (P&P) titled, “Discharge Planning, Transfer, And Continuing Care Needs” (undated), the P&P indicated “Discharge 2. The staff member should prepare the patient for discharge by instructing the patient/caregiver to perform necessary care or should work toward making alternate plans for continuing care when further health care is needed. …5. Patients are informed prior to discharge of plans for discharge and the reason for discharge.” a.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on observation interview and record review, the HHA failed to be in compliance with having a current/updated license to furnish services to their 226 discharged patients, and the HHA failed to obtain approval for the New location where he HHA was providing services. These deficient practices resulted in the HHA providing unlicensed care/services to their patients and possible patient decline and placing patients at risk of not being able to reach their highest potential due to non-compliance with the Federal/state and local laws. On 8/20/2024, at 11 a.m., a complaint validation survey (a type of validation survey to assess whether an accredited provider is meeting Medicare health and safety requirements) was conducted at the HHA. Observation of the building directory listed Agency 1 as the Home Health Agency occupying suite 200. Upon arrival, the door of suite 200 listed agency 2 as suite 200A and Agency 3 as suite 200B with the new address and telephone number on the agency's sign. During an interview on 8/20/2024 at 1:41 pm with the Administrator (ADM), at the HHA, the ADM stated she is the owner and ADM for all four of her agencies: Agency 1-Hygiea Home Health Care. Agency 2-(Prospect Home Health Care. Agency 3-MG Home Health Care Inc. Agency 4- (Asklepius Home HealthCare. The ADM further stated that Agency 1, Agency 2, Agency 3 and Agency 4 all have the same Administrator Designee (ADD), Director of Patient Care Services (DPCS) and Director of Patient Care Services Designee (DPCSD). The administrator stated all patients had been discharged from all four agencies. A review of the HHA’s active patient census indicated a total of 226 patients had been discharged from the home health agency. A review of the form titled, "Standard Office Lease" indicated the lease between Agency 3 and the Lessor was obtained on 12/31/2020 . During an interview with the administrator on 8/20/2024, at 3pm, she stated she was not aware that Agency 3's license had been revoked since the Department of Public Health's Application Branch had took and cashed her check that was sent to them for renewal and that she had been providing at some point in time. The Administrator was unable to provide the survey team Agency 3's current license A review of the California Department of Public Health's ,"Licensed Revocation Letter (non-Payment ) dated 12/21/2023, indicated the license revocation latter was issued on 12/21/2024, due to the agency's license being expired on 3/8/2022, and the license renewal application and necessary fees had not been received. The revocation letter mentioned the above was sent to the agency’s approved address which was not at the current location. A review of the form titled, "Centralized Application Branch Facility Closure Checklist" indicated the Facility Closure Category was Involuntary as of 12/21/2023. On 8/23/2024, at 5:30 p.m., the survey team was unable to complete the survey tasks and had not conducted an exit conference, with the Administrator because she told the survey team that she had a flight to leave the country for 10 days to deal with a personal matter. The Administrator assigned her long term nurse consultant to continue with the survey but the nurse consultant left and the Administrator Designee had to leave for the day.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure a governing body (designated individuals acting as such, is responsible for the agency’s overall management and operation, the provision of home health services, fiscal [relating to government revenue, especially taxes] operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program) assume responsibility for the operations of the HHA by failing to: 1a. Ensure the HHA’s Administrator (ADM, appointed by and report to the governing body, responsible for the day-to-day operation of the HHA, ensure the clinical manager [provides oversight of all patient care services and personnel) performed her responsibilities for the day-to-day operations of the agency, which included maintaining compliance with the federal regulations. 1b. Ensure the HHA’s ADM ensured a clinical manager was available during all operating hours. 2. Ensure the agency’s Director of Patient Care Services (DPCS, have overall responsibility for coordination of patient care services and responsible for all activities relevant to the patient care services furnished including the development of personnel qualifications and the assignment of personnel) provided oversight to ensure the clinical records were accurate and completed for seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). These failures had the potential to result in disruption of patient care and services for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7, receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. (Refer to G942). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Organization and administration of services and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure a governing body (designated individuals acting as such, is responsible for the agency’s overall management and operation, the provision of home health services, fiscal [relating to government revenue, especially taxes] operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program) assume responsibility for the operations of the HHA by failing to: 1a. Ensure the HHA’s Administrator (ADM, appointed by and report to the governing body, responsible for the day-to-day operation of the HHA, ensure the clinical manager [provides oversight of all patient care services and personnel) performed her responsibilities for the day-to-day operations of the agency, which included maintaining compliance with the federal regulations. 1b. Ensure the HHA’s ADM ensured a clinical manager was available during all operating hours. 2. Ensure the agency’s Director of Patient Care Services (DPCS, have overall responsibility for coordination of patient care services and responsible for all activities relevant to the patient care services furnished including the development of personnel qualifications and the assignment of personnel) provided oversight to ensure the clinical records were accurate and completed for seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). These failures had the potential to result in disruption of patient care and services for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7, receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024, at 5:14 p.m., the Department called and Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the HHA’s Administrator Designee (ADD, a similarly qualified [qualified as administrator] designee available in the administrator's absence) related to the HHA’s failure to ensure a governing body assumed responsibility for the operations of the HHA, ensure the HHA’s ADM ensured a clinical manager was available during all operating hours, and ensure the agency’s DPCS provided oversight to ensure the clinical records were completed for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7. The non-compliance had the potential to result in disruption of patient care and services for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7, receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024, at 5:30 p.m., the Administrator Designee (AD) told the survey team the agency would be closed (for business) and would no longer be opened. HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team was not able to complete the survey tasks and could not exit (end) the survey. Findings: 1. During an interview on 8/20/2024 at 1:41 p.m., The ADM stated Agency 1, Agency 2, Agency 3, and Agency 4 all have the same ADD, DPCS, and Director of Patient Care Services Designee (DPCSD, similarly qualified [qualified as DPCS] designee available in the DPCS absence). The ADM stated her family owns all four HHA and the ADM was physically unable to run all the agencies due to her family member was very sick and receiving treatment in another country. The ADM stated she was the one responsible for the day- to- day operation of the agency however, she has not been overseeing these agencies since she was informed about Agency 1 licensed being revoke (date not specified). During an interview on 8/22/2024 at 4 p.m., with the ADM, the ADM stated the DPCS was the clinical manager and would be available and present in the HHA office the following day (8/23/2024) for any questions and assistance needed. During an interview on 8/23/2024 at 1:43 p.m., with the ADM, the ADM stated the DPCS has not arrived yet. The ADM stated she attempted to call the DPCS in the morning to confirm her arrival to the HHA, but the DPCS did not answer. The ADM stated she sent the ADMD to go look for the DPCS at DPCS home, but no one answered and opened the door. The ADM stated she was unable to locate the DPCS and the DPCS continued to not have any communication with HHA. The ADM stated she had to leave emergently out of the country for personal reasons and stated a second DPCSD would be arriving soon, within a couple of minutes. During an interview on 8/23/2024 at 1:56 p.m., with the Consultant (CON), the CON stated she had known the ADM for about eleven years, working as ADM’s consultant for Agency 4. The CON stated she was not aware of or knew information about Agency 1, Agency 2 or Agency 3 and the last time she had worked for the ADM was a year ago and it was for Agency 4. The CON stated she was not DPCSD for Agency 3. The CON stated she was a consultant, and stated the ADM contacted her today asking her to help her with survey as she did not have anyone else available. During an interview on 8/23/2024 at 2:10 p.m. with DPCSD 2, DPCSD 2 stated she has not worked for Agency 1, Agency 2, Agency 3, and Agency 4 since June or July of 2024. DPCSD 2 stated her job role was visiting nurse for open cases for start of care for patients and was not the DPCS or DPCSD. DPCSD 2 stated that in June or July she did not provide a letter of resignation to the ADM but did verbally inform the ADM of her departure (resignation). DPCSD 2 stated at time of working for Agency 1, Agency 2, Agency 3, and Agency 4 there was a DPCS but no DPCSD. During a record review on 8/23/2024 at 1:20 p.m. of DPCS employee file, it was noted that the application the DPCS filled out did not specify the name of the HHA for which the DPCS applied for or would be working for. During a review of the HHA organizational chart (undated), it was noted that the DPCSD on the organizational chart was DPCSD 1 and not DPCSD 2. During the CV survey conducted from 8/20/2024 to 8/23/2024, The DPCS and the DPCSD 1 could not be reached via by telephone and was not available in person at the HHA. During a review of HHA’s policy and procedure (P&P) titled, “Care Service Coordination” dated revised 11/2022, the P&P indicated each patient will be assigned a case manager upon admission by the clinical director or clinical supervisor. It will be the responsibility of the case manager to facilitate communication about changes in the patient status among assigned personnel. A registered nurse will be assigned to a patient receiving skilled nursing. The name of the case manager will be clearly documented in the clinical record. The care coordination should include regularly occurring telephone or email communication among team members. 2. During a concurrent interview and record review on 8/22/2024 at 1:45 p.m., clinical records for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6 and Patient 7 were reviewed with the ADM. Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 clinical records indicated missing or discrepancy with discharge summary and skilled notes. The ADM stated she did not know anything about the missing documents and discrepancies since she was not a nurse. The survey team requested the presence of the DPCS or DPCSD but the ADM were not able to locate them. 2a. During an interview on 8/21/2024 at 11:15 a.m., in Patient 1 home, Patient 1 stated he has been a patient with Agency 3 for four to five years, on and off, and was still being seen and visited by a skilled nursing from Agency 3. Patient 1 stated he was not aware that he has been discharged from Agency 3. During a review of Patient 1’s record titled, “Patient Profile [comprehensive summary of health related information for an individual patient that includes personal, demographic details, contact information and a thorough record of clinical data”, Patient 1 Profile indicated a start of care (SOC) of 5/15/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar) and a secondary diagnosis of primary osteoarthritis (causes joint [the connection between bones or other hard structures in the body] pain, swelling, and tenderness) of right shoulder. During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care” for the certification period of 5/15/24 to 7/13/24, the “Home Health Certification and Plan of Care” indicated skilled nurse frequency visit of two times a week for two weeks, one time a week for seven weeks and physical therapy (PT) to evaluate. 2b. During an interview on 8/21/2024 at 2 p.m., with Patient 2, Patient 2 stated she was a new patient to Agency 3, for one month, and the last home visit by a skilled nursing from HHA was on Monday 8/19/2024 and was expecting to get another visit by the end of the week. During a review of Patient 2’s record titled “Patient Profile”, Patient 2 Profile indicated a SOC of 5/8/2024, with a primary diagnosis of bilateral primary osteoarthritis of knee and a secondary diagnosis of polyosteoarthritis (having arthritis [inflammation of the joint] that affects five or more joints at the same time). During a review of Patient 2’s record titled, “Home Health Certification and Plan of Care”, for the certification period of 5/8/2024 to 7/6/2024, the “Home Health Certification and Plan of Care” indicated skilled nursing frequency visit of one time a week for one week, two times a week for two weeks, one time a week for six weeks and PT to evaluate. 2c. During a review of Patient 3’s record titled, “Patient Profile”, Patient 3 Profile indicated a SOC of 3/16/2024, with a primary diagnosis of bilateral primary osteoarthritis of first carpometacarpal joints (base of the thumb that connects the thumb to the wrist) and a secondary diagnosis of bilateral primary osteoarthritis of knee. During a review of Patient 2’s record titled, “Home Health Certification and Plan of Care”, for the certification period of 5/8/2024 to 7/6/2024, the “Home Health Certification and Plan of Care” indicated skilled nursing frequency visit of one time a week for one week, two times a week for two weeks, one time a week for six weeks and PT to evaluate. 2d. During a review of Patient 4’s record titled, “Patient Profile”, Patient 4 Profile indicated a SOC date of 3/14/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hereditary and idiopathic neuropathies (are both nervous system disorders that can affect nerve functions) During a review of Patient 4’s record titled, “Home Health Certification and Plan of Care”, for the certification period of 3/14/2024 to 5/12/2024, the “Home Health Certification and Plan of Care” indicated skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” form also indicated a physician order for PT to evaluate Patient 4. There was no contact information in Patient 4’s Electronic Medical Record. 2e. During an interview on 8/21/2024 at 10 a.m., at Patient 5 Home, Patient 5 stated that she has been a patient of Agency 3 for over one year and was still currently being seen by a skilled nursing from Agency 3. During a review of Patient 5’s record titled “Patient Profile”, the Patient Profile indicated a SOC date of 7/23/2024, with diagnoses of arthritis multiple sites, and spondylosis (the development of age-related arthritis that affects the spine). During a review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, for the certification period of 7/23/2024 to 9/20/2024, the “Home Health Certification and Plan of Care” indicated the skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” indicated a physician order for PT to evaluate Patient 5. There was no contact information in Patient 4’s Electronic Medical Record. f. During a review of Patient 6’s record titled, “Patient Profile”, the “Patient Profile” indicated a start of care date of 8/6/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hypertensive heart disease without heart failure (a category of heart disease that occurs when high blood pressure over a long period of time causes heart problems). During a review of Patient 6’s record titled, “Home Health Certification and Plan of Care”, for the certification period of 8/6/2024 to 10/4/2024, the “Home Health Certification and Plan of Care” indicated the skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” indicated a physician order for PT to evaluate Patient 6. g. During a review of Patient 7’s record titled, “Patient Profile”, Patient 7 Profile indicated a SOC date of 3/13/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). During a review of Patient 7’s record titled, “Home Health Certification and Plan of Care”, for the certification period of 3/13/2024 to 5/11/2024, the “Home Health Certification and Plan of Care” indicated the skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” also indicated a physician order for PT to evaluate Patient 7. During a review of the HHA’s policy and procedure (P&P) titled, “Patients’ Health Records Availability”, undated, indicated the agency shall safeguard the information in the record against loss, defacement, tampering or use by unauthorized persons. During a review of the HHA’s P&P titled, “Patient record: Protection and retention”, undated, indicated all patient records shall be housed in physically secure areas under the immediate control of designated staff. Access to areas housing patient records shall be limited to authorized personnel. When in use within an agency, records should be kept in secured areas at all times. Records should not be left unattended in areas accessible to unauthorized individuals.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure to safeguard the patient’s clinical records for seven of 226 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) from possible loss of clinical records or unauthorized use of patients’ information. This failure had the potential to result in loss or unauthorized use of patients’ information or clinical records that could result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 receiving wrong treatment, poor patient care, unclear evaluations and treatment plans that increased the risk of these patients to hospitalization and serious injury, harm, and death. (Refer to G1028). The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with the Clinical Records to ensure quality of care was provided to the patients who were assessed to receive home care and services.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure to safeguard the patient’s clinical records for seven of 226 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) from possible loss of clinical records or unauthorized use of patients’ information. This failure had the potential to result in loss or unauthorized use of patients’ information or clinical records that could result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 receiving wrong treatment, poor patient care, unclear evaluations and treatment plans that increased the risk of these patients to hospitalization and serious injury, harm, and death. On 8/20/2024, at 4:40 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) related to the HHA failure to ensure to safeguard Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 clinical records from possible loss or unauthorized access. The non-compliance has the potential to result in unauthorized use of patients’ information or loss of clinical records that could result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 receiving wrong treatment, poor patient care, unclear evaluations and treatment plans that increased the risk of these patients to hospitalization and serious injury, harm, and death. On 8/23/2024 at 5:30 p.m., the Administrator Designee (AD) told the survey team the agency would be closed (for business) and would no longer be opened. The HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team was not able to complete the survey tasks and could not exit (end) the survey. Findings: a. During an observation on 8/20/2024, at 11 a.m., in Agency 4, there were 15 boxes of patients’ charts (complete and total record of a patient’s clinical data and medical history) found stored on the floor by the main entrance hallway of Agency 4. During a concurrent observation and interview on 8/20/2024 at 2:30 p.m., in the main entrance hallway of Agency 4, with the ADM, the 15 boxes of patients' charts were still found stored on the floor. The ADM stated that there were 15 boxes of patients charts in the hallway of Agency 4, and the boxes included a combination of patients’ discharge records from Agency 1, Agency 2, Agency 3, and Agency 4. The ADM stated she was aware the patients' charts were not being safeguarded correctly by the HHA. The ADM stated the HHA’s patients' charts were not being safeguarded because she was cleaning out Agency 1, Agency 2, Agency 3, and Agency 4 due to being in the process of selling them. During an interview on 8/21/2024 at 11:15 a.m., in Patient 1 home, Patient 1 stated he has been a patient with Agency 3 for four to five years, on and off, and was still being seen and visited by a skilled nursing from Agency 3. During a review of Patient 1’s record titled, “Patient Profile”, Patient 1 Profile indicated a start of care (SOC) of 5/15/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar) and a secondary diagnosis of primary osteoarthritis (causes joint [the connection between bones or other hard structures in the body] pain, swelling, and tenderness) of right shoulder. During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care” for the certification period of 5/15/24 to 7/13/24, the “Home Health Certification and Plan of Care” indicated skilled nurse frequency visit of two times a week for two weeks, one time a week for seven weeks and physical therapy (PT) to evaluate. b. During an interview on 8/21/2024 at 2 p.m., with Patient 2, Patient 2 stated she was a new patient to Agency 3, for one month, and the last home visit by a skilled nursing from HHA was on Monday 8/19/2024 and was expecting to get another visit by the end of the week. During a review of Patient 2’s record titled “Patient Profile”, Patient 2 Profile indicated a SOC of 5/8/2024, with a primary diagnosis of bilateral primary osteoarthritis of knee and a secondary diagnosis of polyosteoarthritis (having arthritis [inflammation of the joint] that affects five or more joints at the same time). During a review of Patient 2’s record titled, “Home Health Certification and Plan of Care” for the certification period of 5/8/2024 to 7/6/2024, the “Home Health Certification and Plan of Care” indicated skilled nursing frequency visit of one time a week for one week, two times a week for two weeks, one time a week for six weeks and PT to evaluate. c. During a review of Patient 3’s record titled “Patient Profile”, Patient 3 Profile indicated a SOC of 3/16/2024, with a primary diagnosis of bilateral primary osteoarthritis of first carpometacarpal joints (base of the thumb that connects the thumb to the wrist) and a secondary diagnosis of bilateral primary osteoarthritis of knee. During a review of Patient 3’s record titled, “Home Health Certification and Plan of Care” for the certification period of 5/15/2024 to 7/13/2024, the “Home Health Certification and Plan of Care” indicated skilled nursing frequency visit of one time for one week, two times a week for two weeks, one time a week for six weeks and PT to evaluate. d. During a review of Patient 4’s record titled, “Patient Profile”, Patient 4 Profile indicated a SOC date of 3/14/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hereditary and idiopathic neuropathies (are both nervous system disorders that can affect nerve functions) During a review of Patient 4’s record titled, “Home Health Certification and Plan of Care” for the certification period of 3/14/2024 to 5/12/2024, the “Home Health Certification and Plan of Care” indicated skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” form also indicated a physician order for PT to evaluate Patient 4. e. During an interview on 8/21/2024 at 10 a.m., at Patient 5 Home, Patient 5 stated that she has been a patient with this home health agency for over one year and was still currently being seen by Agency 3. During a review of Patient 5’s record titled “Patient Profile”, Patient 5 Profile indicated a SOC date of 7/23/2024, with diagnoses of arthritis multiple sites, and spondylosis (the development of age-related arthritis that affects the spine). During a review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, the “Home Health Certification and Plan of Care”, for the certification period of 7/23/2024 to 9/20/2024 indicated the skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” indicated a physician order for PT to evaluate Patient 5. f. During a review of Patient 6’s record titled, “Patient Profile”, the “Patient Profile” indicated a start of care date of 8/6/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hypertensive heart disease without heart failure (a category of heart disease that occurs when high blood pressure over a long period of time causes heart problems). During a review of Patient 6’s record titled, “Home Health Certification and Plan of Care”, for the certification period of 8/6/2024 to 10/4/2024, the “Home Health Certification and Plan of Care” indicated the Skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” indicated a physician order for PT to evaluate Patient 6. g. During a review of Patient 7’s record tiled, “Patient Profile”, Patient 7 Profile indicated a SOC date of 3/13/2024, with diagnoses of diabetes mellitus type 2 with hyperglycemia, and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). During a review of Patient 7’s record titled, “Home Health Certification and Plan of Care”, the “Home Health Certification and Plan of Care”, for the certification period of 3/13/2024 to 5/11/2024, indicated the skilled nurse to visit one time a week for one week, two times a week for two weeks and one time a week for six weeks to assess and educate patient on disease process and medication regime. The “Home Health Certification and Plan of Care” also indicated a physician order for PT to evaluate Patient 7. During a review of the HHA’s policy and procedure (P&P) titled, “Patients’ Health Records Availability”, undated, indicated the agency shall safeguard the information in the record against loss, defacement, tampering or use by unauthorized persons. The P&P indicated the agency shall protect patients from unnecessary intrusion into their private lives by safeguarding the health information entrusted to them. During a review of the HHA’s P&P titled, “Patient record: Protection and retention”, undated, indicated all patient records shall be housed in physically secure areas under the immediate control of designated staff. Access to areas housing patient records shall be limited to authorized personnel. When in use within an agency, records should be kept in secured areas at all times. Records should not be left unattended in areas accessible to unauthorized individuals.