Every finding on record at Montebello Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey. Representing the Department of Public Health: Surveyor ID # 43979, Health Facilities Evaluator Nurse Surveyor ID # 43929, Health Facilities Evaluator Nurse Census: 71 Unduplicated admissions: 71 Sample Size: 8 Home Visits: 3 Closed Record review: 2 The Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) situation on 8/10/2023, at 4:20 p.m., in the presence of the agency’s Administrator (ADM), Director of Patient Care Services (DPCS), Quality Assurance (QA), Chief Operating Officer (COO), Intake Coordinator (IC), and Human Resources (HR). The agency failed to perform a comprehensive assessment (a tool used by nurses to evaluate a patient's complete health status) for one of eight sampled patients (Patient 2) by failing to: 1. Complete Patient 2's comprehensive assessment (a tool used by nurses to evaluate a patient's complete health status) within five calendar days of Patient 2's admission to the agency that started on 7/15/2023 to address Patient 2's diagnosis of Type 2 diabetes mellitus (DM, a medical condition characterized by the body's inability to regulate blood sugar levels). 2. Ensure to follow Patient 2’s General Acute Care Hospital (GACH) physician's discharge home instructions to perform accu-checks (blood glucose [sugar] testing) and monitor Patient 2’s blood sugar levels before meals and at bedtime. 3. Develop an individualized plan of care for the management of Patient 2’s diagnosis of DM that was identified from Patient 2’s GACH discharge summary. 4. Coordinate with Patient 2's Primary Medical Doctor 4 (PMD 4) to obtain physician orders in the management of Patient 2's diabetes. 5. Provide Patient 2 an accu-check device to check Patient 2’s blood sugar levels as indicated in Patient 2’s discharge to home instructions from GACH. These deficient practices had the potential for Patient 2 to develop hypoglycemia (low blood sugar levels) or hyperglycemia (high blood sugar levels) that could lead to serious harm, hospitalization, or death. On 8/11/2023, at 2 p.m., the agency submitted an acceptable IJ removal plan (a list of steps taken to correct the deficient practices). While onsite, the surveyors verified and confirmed the implementation of the IJ removal plan by observation, interview, record review. The surveyors confirmed the removal of the IJ on 8/11/2023 at 3:36 pm in the presence of the ADM, DPCS, QA, HR, and the IC. The acceptable IJ removal plan included the following: 1. On 8/10/2023 the agency updated Patient 2’s diagnosis of DM in Patient 2’s clinical record and developed a plan of care to address Patient 2’s diagnosis of DM. 2. On 8/10/2023, the agency contacted Resident 2’s primary care physician and Patient 2’s primary care physician ordered the following: a. glucometer machine (accu-check device). b. alcohol wipes. c. lancets (small devices that provide a way to take blood samples). d. accu-check strips (use to collect the blood sample). e. sharp container (a hard plastic container that is used to safely dispose of needles and or sharp objects). f. For the Licensed Nurses (in general) to conduct daily visits for one week starting 8/11/2023 and check Patient 2’s blood sugar every morning. g. To notify Patient 2’s PMD 4 if Patient 2’s blood sugar was below 60 milligrams per deciliter (mg/dL, unit of measure) or above 300 mg/dl. h. For Patient 2 to receive Metformin (medication to control high blood sugar) 500 milligrams (mg, unit of measurement) three times a day. 2. On 8/11/2023 Patient 2 received the above orders. 3. On 8/11/2023, the Director of Patient Care Services (DPCS) completed Patient 2’s comprehensive assessment. 4. On 8/11/2023, the DPCS checked Patient’s blood sugar and Patient 2’s blood sugar results were 274 mg/dL (high, normal ranges between 70 and 100 mg/dL). The following Conditions of Participation (COP) were not met: 484.50 Condition of participation: Patient Rights 484.55 Condition of Participation: Comprehensive Assessment of Patients 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care 484.75 Condition of Participation for Skilled Professional Services 484.110 Condition of Participation Clinical Records

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Patient Rights was met as follows: 1.The HHA failed to provide and/or obtain information of the Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) from one of eight sample patients (Patient 5) or their representative. (Refer to G410). 2.The HHA failed to provide a written notice of the patient’s bill of rights (document that provide patients with information on how they can reasonably expect to be treated during the course of care) in a language easily understood (Spanish) to one of eight sampled patients (Patient 2). (Refer to G412). 3. The HHA failed to provide all the services in the Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative) to three of eight sampled patients (Patient 4, Patient 5, Patient 6). (Refer to G436). 4. The HHA failed to provide and ensure three of eight sampled patients (Patient 1, Patient 2, and Patient 5) received information regarding the State toll free home health hotline, its contact information, its hours of operation, and its purpose. (Refer to G444). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to patients assessed to receive home health services.

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to provide and/or obtain information of the Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) from one of eight sample patients (Patient 5). This failure has the potential to result in the patient's final health care wishes or decisions will not be coordinated to the healthcare professional or staff which could cause confusion during the patient's end of life situation which can go against the patient's right to carry on last wishes and health care decision. Findings: A review of Patient 5’s medical record form titled “Patient Profile by Episode” indicated a Start of Care (SOC) date of 12/8/2022, with diagnoses including Diabetes Mellitus type II (high blood sugar) and Hypertension (high blood pressure). A review of Patient 5's’s medical record titled “Home Health Certification and Plan of Care” dated from 6/6/2023 to 8/4/2023, indicated under section “Advance Directive – Full Code”. A review of Patient 5’s medical record titled “Recertification (follow-up) assessment” dated from 6/6/2023 to 8/4/2023, indicated under section “Advance Directive – Full Code”. A review of Patient 5’s medical record titled “History and Physical” dated 5/11/2023, indicated “code status DNR/DNI (Do not resuscitate/Do not intubate) …” During a concurrent interview and record review on 8/10/2023, at 3:26 p.m., with the Director of Patient Care Services (DPCS) of Patient 5’s Electronic Medical Record (EMR), the DPCS stated the last History and Physical (H&P) was conducted on 5/11/2023 indicating Patient 5 was DNR (Do Not Resuscitate). DPCS stated that it was important to know a patient’s status because if the opposite is performed it could go against patient's wishes. DPCS stated, “It is considered a patient rights issue because we did not carry out the patient's wishes.” During a concurrent interview and record review on 8/11/2023, at 3:30 p.m., with DPCS of Patient 5’s Electronic Medical Record (EMR), stated that the admitting nurse did not ask Patient 5’s about his last wishes. DPCS was unable to locate Patient 5’s Advance Directive in the EMR. A review of facility’s policy and procedure titled, “Rights and Responsibilities” revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: F. The right to formulate Advance Directives and the organization’s policy on the withholding of resuscitative services and the withdrawal of life-sustaining treatment and to lodge complaints concerning the implementation of the advance directive requirements.” A review of facility’s policy and procedure titled, “Advance Directives” revised 4/2021, indicated “Upon admission, the clinician will provide information regarding a patient right to make decisions concerning health care, which include the right to accept or refuse medical or surgical treatment, even if the treatment is life-sustaining, the right to execute Advance Directives, and applicable organization policies. All clinicians providing care for the patient will: review the Advance Directive and report any discrepancies between the Directive and current treatment plan to the attending physician, clinical supervisor, and the patient.” A review of facility’s policy and procedure titled, “Do Not resuscitate/Do Not Intubate” revised 4/2021, indicated “The organization will follow the patients Advance Directive completed according to the requirements of the jurisdiction of the state in which the patient resides. A review of facility’s policy and procedure titled, “Initial and Comprehensive Assessment” revised 4/2021, indicated “During the initial and comprehensive patient assessment, all baseline date to be used in measuring the patients progress… and other relevant information will be documented in the patients’ clinical record…Presence of any Advance Directive… Wishes regarding care, treatment and end of life decisions.”

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to provide a written notice of the patient’s bill of rights in a language easily understood (Spanish) to one of eight sampled patients (Patient 2). This failure resulted in a violation of patient’s rights due to patients and representatives not understanding their rights and responsibilities as a patient while under the HHA’s care. Findings: A review of Patient’s 2 “Patient Profile” indicated a start of care on 7/15/23, with diagnoses including hypertensive heart disease without heart failure (high blood pressure). During an observation of the home visit on 8/9/23, at 10:20 a.m., an agency binder (information provided by the HHA regarding patient rights, plan of care, medication list, and information on resources) was observed. The agency's literatures in the packet provided to the patients were in English language. During an interview on 8/9/23, at 10:20 a.m., Patient 2 stated his preferred language for reading and speaking was Spanish. During an interview on 8/11/23, at 2:42 p.m., the administrator (ADM) stated the agency had a “Patient Handbook” in four other languages, including Spanish. The ADM stated she did not know why Patient 2 did not have written information in his preferred language. A review of facility’s policy and procedure titled “Facilitating Communication” revised 4/2021, indicated “Personnel will… use forms of compunction appropriate to meet patients’ needs. All patients will receive a copy of: Patient Rights and Responsibilities, Compliant/Grievance Process, Advance directive Information Statement; these forms will be available in English and in other languages… The organization shall provide verbal notice of the patients’ rights and responsibilities in the patients primary or preferred language and in a manner the individual understands… Written information will be provided to patient in … the predominant non-English languages of the population served.”

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview, and record review the Home Health Agency (HHA) failed to provide all the services as indicated in the Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative) to three of eight sampled patients (Patient 4, Patient 5, and Patient 6). -Patient 4 did not receive education from the HHA staff about managing the diabetes (too much sugar in the blood). -Patient 5 's Skilled Nurse (SN) visit for the week of 7/30/2023 disclosed the blood sugar levels were not monitored. The SN failed to give instructions or education to the patient/caregiver regarding signs and symptoms of hyperglycemia and hypoglycemia (high and low blood sugar). -Patient 6's Skilled Nursing (SN) missing visits for the week of 7/30/2023, and the patient's blood sugar levels were not monitored or educated for hyper and/or hypoglycemia. This failure has the potential to result in patients not receiving their prescribed treatments which could lead to the decline of patients' health, affecting health progression, and not meeting the patient care goals. Findings: A review of Patient’s 4 “Patient Profile” indicated a start of care date of 9/7/22, with diagnoses including Type 2 diabetes (high levels of sugar in the blood, a chronic condition). During a concurrent interview and record review on 8/11/23, at 1:10 p.m., Patient 4’s record titled, “Plan of Care” for certification period 7/4/23-9/1/23, was reviewed with the Administrator (ADM). The record indicated a skilled nurse (SN) was to visit Patient 4 once a week for 9 weeks, instruct and teach about signs and symptoms of low (hypoglycemia), high sugar (hyperglycemia) in the blood, and monitor the level of sugar in the blood. The ADM stated it was important for the nurse visiting Patient 4 to take a reading on the blood sugar level to make sure it was in the desired range as ordered by the doctor. The ADM stated it was important to teach the patient about diabetes, so the patient knows how to manage the condition when the HHA staff are not there. If patient does not receive diabetes teaching, there can be complications of diabetes such as hypo and hyper glycemia, which can result in hospitalization. During a concurrent interview and record review on 8/11/23, at 1:25 p.m., Patient 4’s record titled, “Nursing Progress Note”, for 7/7/23,7/14/23, 7/21/23, and 7/28/23, was reviewed with the ADM. The ADM stated there was no blood sugar levels taken and no diabetes management education provided to the patient. A review of Patient 5’s medical record form titled “Patient Profile by Episode” indicated a Start of Care (SOC) date of 12/8/2022, diagnoses including Diabetes Mellitus type II (DMII - high blood sugar) and Hypertension (high blood pressure). A review of Patient 5’s medical record titled “Home Health Certification and Plan of Care” dated from 6/6/2023 to 8/4/2023, indicated “Skilled Nurse frequency visits: 1W8 (once a week for eight weeks), start on week of August 6, 2023.” It also indicated “Skilled nurse to perform observation/assessment of … blood sugar monitoring… Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer; Skilled nurse to report to MD of patients BS (blood sugar) of less than 80mg/dl or more than 300 mg/dl…”. A review of Patient 5’s Assisted Living Facility’s medical record titled, “Central ordered Medication and Destruction Record” indicated there was no mention of blood sugar level checks. A review of Patient 5’s Electronic Medical Record (EMR) on 8/8/2023, at 8:37 p.m., indicated the last skilled nursing note was dated 8/3/2023 which was not completed or signed. During a concurrent interview and record review on 8/10/2023, at 3:54 p.m. with the Director of Patient Care Services (DPCS) of Patient 5’s Electronic Medical Record (EMR), DPCS stated the patient has SN visits scheduled once a week. DPCS stated that the SN forgot to document the visit on 8/3/2023. DPCS stated that she expects nurses to submit their notes right away or by the weekend. During a joint home visit on 8/9/2023, at 11:20 a.m. with License Vocational Nurse 1 (LVN1) to Patient 5’s residence at the Assisted Living Facility (ALF), LVN1 completed a skilled nurse visit. The ALF Medication Nurse (MN) stated that Patient 5 has never had his blood sugar level checked while at the ALF. During a concurrent interview and record review on 8/10/2023, at 4:13 p.m., with the DPCS of Patient 5’s Electronic Medical Record (EMR), DPCS stated, “Patient’s diagnosis is Type 2 DM, he has not been monitored for his diabetes. The patient will end up going in shock if his sugar is low or too high, which will require hospitalization.” A review of Patient 6’s medical record form titled “Patient Profile by Episode” indicated a Start of Care (SOC) date of 7/8/2023, diagnoses including Hypertension (high blood pressure) and Diabetes Mellitus Type 2 (high blood sugar). A review of Patient 6’s medical record titled “Home Health Certification and Plan of Care” dated from 7/8/2023 to 9/5/2023, indicated “Skilled Nurse frequency visits: 1W9 (once a week for nine weeks), reassess on the 9th week.” It also indicated “Skilled nurse to perform observation/assessment of … all body systems emphasizing on … endocrine status… Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer, diabetic skin and foot care; Skilled nurse to report to MD of patients BS (blood sugar) of less than 80mg/dl or more than 300 mg/dl…”. A review of Patient 6’s Electronic Medical Record (EMR) on 8/8/2023, at 10 p.m., indicated the last skilled nursing note was dated 7/29/2023. During a telephone interview on 8/9/2023, at 3 p.m., with Patient 6’s Care Giver (CG1), CG1 stated that Patient 6 was admitted on 7/8/2023 and has not received the glucometer (device to check the level of sugar in the blood) from the HHA. During a concurrent interview and record review on 8/11/2023, at 11 a.m., with the Administrator (ADM) stated, that Patient 6’s medical doctor ordered the glucometer and the HHA's responsibility was to call the pharmacy to check it. ADM stated, while reviewing the EMR stated that no one has followed it up. ADM stated it was important to educate patients on their POC, “so they know the management of their plan of care. A review of facility’s policy and procedure titled, “Patient Notification of Changes in Care” revised 4/2021, indicated “When a visit cannot be made because of unforeseen problems, personnel will immediately notify the office.” A review of facility’s policy and procedure titled, “Rights and Responsibilities” revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: I. The organization shall ensure that the patient receives all services outlined in the plan of care.” A review of facility’s policy and procedure titled, “Missed Visits” revised 4/2021, indicated “Missed visits will be documented in the clinical record. If an aide visit is missed the aide will contact the case manager or clinical supervisor…” A review of facility’s form titled “Registered Nurse – Job Title/Position” revised 4/2021, indicated “Communicates with the physician regarding the patients’ needs and reports any changes in the patient’s condition.”

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide and ensure three of eight sampled patients (Patient 1, Patient 2, and Patient 5) were advised of the State Toll Free home health hotline number, hours of operation, and its purpose. This failure has the potential to result in the patients will lack knowledge of their right to lodge their complaints regarding patient care issues and the resolution of their complaints. Findings: A review of Patient’s 1 “Patient Profile” indicated a start of care on 1/20/23, with diagnoses including chronic pain. During a concurrent observation and interview of the home visit on 8/9/23, at 11:45 a.m., there was no agency binder in Patient 1’s home. Patient 1 stated she did not know how to contact the state department because she did not have the information. A review of Patient’s 2 “Patient Profile” indicated a start of care on 7/15/23, with diagnoses including hypertensive heart disease without heart failure (high blood pressure). During the home visit on 8/9/23, at 10:20 a.m., at Patient 2's residence an agency binder (information provided by the HHA regarding patient rights, plan of care, medication list, and information on resources) was reviewed. During an interview on 8/9/23, at 10:30 a.m., Patient 2 stated he did not have the information to call the state department for concerns regarding the care provided by the HHA. A review of Patient 5’s medical record form titled “Patient Profile by Episode” indicated P5 had a Start of Care (SOC) date of 12/8/2022, diagnoses including Diabetes Mellitus type II (high blood sugar) and Hypertension (high blood pressure). During a joint home visit on 8/9/2023, at 10 a.m., with License Vocational Nurse 1 (LVN1) at the Assisted Living Facility (ALF) where Patient 5 resided, Patient 5 stated that the HHA folder was brought to his room this morning because they told him a surveyor was coming. Patient 5 stated that he did not know what was inside to folder because it was the first time, he saw it. Patient 5 also stated that he was never provided with the State hotline number and its purpose. During an interview on 8/11/2023, at 2:42 p.m., with the Administrator (ADM), the ADM stated that the HHA binder was provided and explained to all patients. ADM stated that it’s the patients right to know their care. A review of facility’s policy and procedure titled, “Rights and Responsibilities” revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: O. The right to voice a complaint or concern… The availability of other sources to receive questions and complaints and assist in resolution. The availability of the applicable toll-free home health agency hotline… to receive questions or complaints…”

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment (a tool used by nurses to evaluate a patient's complete health status) of Patients as follows: 1. The HHA failed to perform an accurate comprehensive assessment for one of eight sampled patients (Patient 2,), by failing to: (Refer to G520). -Complete Patient 2’s (P2) comprehensive assessment within five calendar days of Patient 2’s admission that started on 7/15/2023 that addressed Patient 2’s diagnosis of Type 2 diabetes mellitus (high levels of sugar in the blood, a chronic condition). -Thoroughly review the General Acute Care Hospital (GACH) doctor’s discharge summary with instructions to perform accu-checks (taking a small blood sample from the finger, to monitor blood sugar levels) before every meal and at bedtime. -Formulate a plan of care for the management of diabetes as soon as the Registered Nurse (RN) identified in the GACH’S discharge summary. -Coordinate with Patient 2’s primary care doctor to obtain orders in the management of P2’s diabetes. -Ensure to provide Patient 2’s equipment to check blood sugar levels as indicated in the discharge home instructions. The RN attempted to check P2’s blood sugar during the home visit on 8/9/23, but the strips needed to place the blood sample were expired. 2. The HHA failed to ensure the comprehensive assessment accurately reflected the patients status for one of eight sampled patients (Patient 5). This failure had the potential to result in misinforming all staff involved with the patients care, and to not know the patient’s current status, which can delay care. (Refer to G526). 3. The HHA failed to review and document all the medications and treatments the patient was currently using for four of eight sampled patients (Patient1, Patient 2, Patient 5 and Patient 6). This failure placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). 4. The Home Health Agency (HHA) failed to ensure a Registered Nurse (RN) updated the comprehensive assessment for the recertification period for five of eight sampled patients (Patient 1, Patient 4, Patient 5, Patient 6 and Patient 8). (Refer to 544). This failure had the potential to result in decline in health status by not assessing the patient’s needs. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health services.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to perform a comprehensive assessment (a tool used by nurses to evaluate a patient's complete health status) for one of eight samples patients (Patient 2) by failing to: 1. Complete Patient 2's comprehensive assessment within five calendar days of Patient 2's admission to the agency that started on 7/15/2023 to address Patient 2's diagnosis of Type 2 diabetes mellitus (DM, a medical condition characterized by the body's inability to regulate blood sugar levels). 2. Ensure to follow Patient 2’s General Acute Care Hospital (GACH) physician's discharge home instructions to perform accu-checks (blood glucose [sugar] testing) and monitor Patient 2’s blood sugar levels before meals and at bedtime. 3. Develop an individualized plan of care for the management of Patient 2’s diagnosis of DM that was identified from Patient 2’s GACH discharge summary. 4. Coordinate with Patient 2's Primary Medical Doctor 4 (PMD 4) to obtain physician orders in the management of Patient 2's diabetes. 5. Provide Patient 2 an accu-check device and supplies to check Patient 2’s blood sugar levels as indicated in Patient 2’s discharge to home instructions from GACH. These deficient practices had the potential for Patient 2 to experience hypoglycemia (low blood sugar levels) or hyperglycemia (high blood sugar levels) that could lead to serious harm, hospitalization, or death. The Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) situation on 8/10/2023, at 4:20 p.m., in the presence of the agency’s Administrator (ADM), Director of Patient Care Services (DPCS), Quality Assurance (QA), Chief Operating Officer (COO), Intake Coordinator (IC), and Human Resources (HR). The agency failed to perform a comprehensive assessment (a tool used by nurses to evaluate a patient's complete health status) for one of eight sampled patients (Patient 2). On 8/11/2023, at 2 p.m., the agency submitted an acceptable IJ removal plan (a list of steps taken to correct the deficient practices). While onsite, the surveyors verified and confirmed the implementation of the IJ removal plan by observation, interview, record review. The surveyors confirmed the removal of the IJ on 8/11/2023 at 3:36 p.m. in the presence of the ADM, DPCS, QA, HR, and the IC. The acceptable IJ removal plan included the following: 1. On 8/10/2023 the agency updated Patient 2’s diagnosis of DM in Patient 2’s clinical record and developed a plan of care to address Patient 2’s diagnosis of DM. 2. On 8/10/2023, the agency contacted Resident 2’s primary care physician and Patient 2’s primary care physician ordered the following: a. glucometer machine (accu-check device). b. alcohol wipes. c. lancets (small devices that provide a way to take blood samples). d. accu-check strips (use to collect the blood sample). e. sharp container (a hard plastic container that is used to safely dispose of needles and or sharp objects). f. For the Licensed Nurses (in general) to conduct daily visits for one week starting 8/11/2023 and check Patient 2’s blood sugar every morning. g. To notify Patient 2’s PMD 4 if Patient 2’s blood sugar was below 60 milligrams per deciliter (mg/dL, unit of measure) or above 300 mg/dl. h. For Patient 2 to receive Metformin (medication to control high blood sugar) 500 milligrams (mg, unit of measurement) three times a day. 2. On 8/11/2023 Patient 2 received the above orders. 3. On 8/11/2023, the Director of Patient Care Services (DPCS) completed Patient 2’s comprehensive assessment. 4. On 8/11/2023, the DPCS checked Patient’s blood sugar and Patient 2’s blood sugar results were 274 mg/dL (high, normal ranges between 70 and 100 mg/dL). Findings: A review of Patient 2’s GACH record titled, “Cardiology Progress Note,” dated 7/14/2023, indicated Patient 2’s blood sugar level was 130 mg/dl (mg-milligrams, per dl-deciliters, unit of measurement), the normal ranges for this level was 70-108 mg/dl. A review of Patient’s 2 “Patient Profile,” indicated a start of care (SOC) on 7/15/2023, with diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure) without heart failure. A record review of Patient 2’s GACH record titled, “Patient Discharge Instructions,” with a printed date of 7/15/2023, indicated to check Patient 2’s blood sugar levels before meals and at bedtime. A review of Patient 2’s document titled, “Reason for Assessment: Start of Care,” dated 8/8/2023, indicated the Director of Patient Care Services (DPCS) visited Patient 2 on 7/15/2023. The record indicated there was no blood sugar levels for Patient 2 since the SOC date on 7/15/2023. During a concurrent interview and record review on 8/8/2023, at 3:23 p.m., Patient 2’s medical record was reviewed with the Quality Assurance staff (QA). The QA stated there was no plan of care (POC) documented in Patient 2’s record. The QA stated the POC was supposed to be done within five days of the start of care, but staff were "swamped," and could not complete the POC. The QA stated the purpose of the POC was the plan of treatment, to guide staff on what needed to be assessed, education needed to be provided, reportable conditions, and who needed to be contacted in case of an emergency. During the home visit observation on 8/9/2023, at 10:15 a.m., the DPCS was observed providing care to Patient 2. Patient 2’s caregiver (PCG) was present during the visit. During an interview on 8/9/2023, at 10:30 a.m., the PCG stated to the DPCS, Patient 2 was diabetic (a person with diabetes). During an interview on 8/9/2023, at 10:39 a.m., Patient 2 stated the last time his blood sugar levels were checked was when he was in the hospital, in July (day unidentified) 2023. During a concurrent observation and interview of the home visit on 8/9/2023, at 10:39 a.m., the DPCS attempted to take Patient 2’s blood sugar levels with the equipment Patient 2 provided. The DPCS reviewed Patient 2’s glucometer (a machine that reads blood sugar levels) and stated she could not use the machine because the strips (use to collect the blood sample) were expired and there were no lancets (a small sharp device used to prick the finger to get a blood sample). During an interview on 8/9/2023, at 10:40 a.m., Patient 2’s PCG stated she did not know who was responsible in providing strips and lancets for the glucometer. The DPCS stated to the PCG to ask the doctor (unidentified) to refill the strips and lancets. During an interview on 8/9/2023, at 10:45 a.m., the DPCS stated she noticed the discharge documents from the GACH indicated to check Patient 2’s blood sugar levels. The DPCS stated the discharge documents did not list diabetic medications and asked the office to call Patient 2’s PMD 4on 7/15/2023 to clarify if diabetic medications were needed. During a home visit on 8/9/2023, at 10:50 a.m., the DPCS told Patient 2’s PCG to clarify with PMD4 if Patient 2’s blood sugar levels needed to be taken. During a concurrent interview and record review on 8/9/2023 at 2:57 p.m., Patient 2’s document titled “Home Health Certification and Plan of Care,” for certification period 7/15/23-9/12/23 was reviewed. The document indicated Medical Director 1’s (MD1) was Patient 2’s doctor. MD 1’s office was contacted and MD 1’s staff stated Patient 2 was not a patient of MD 1. During an interview on 8/9/2023, at 3:04 p.m., Patient 2’s Primary Medical Doctor (PMD 4) stated Patient 2 had diagnoses of type 2 diabetes and diabetic neuropathy (nerve damage because of diabetes). During an interview on 8/10/2023, at 8:51 a.m., PMD 4 stated he was the primary doctor taking care of Patient 2. PMD 4 stated Patient 2 was supposed to be taking diabetic medication three times daily and check his blood sugar while fasting once a day every other day. PMD 4 stated Patient 2’s hemoglobin A1C (HbA1C-a blood test that measures the average level of sugar in the blood over a 3-month period) in June 2023 was 7.7% (high, normal A1C level is below 5.7%, a level of 5.7% to 6.4% indicates prediabetes, and a level of 6.5% or more indicates diabetes). PMD 4 stated the goal for Patient 2 was 7.5%. PMD 4 stated the risks of Patient 2 not taking diabetic medication was complications of uncontrolled diabetes such as diabetic keto acidosis (a serious complication of diabetes), and acute kidney injury. PMD 4 stated the HHA had not contacted him. During an interview on 8/10/2023, at 9:37 a.m., MD 1 stated he was not the primary doctor of Patient 2. MD 1 stated he had never seen, examined or been involved in Patient 2’s care. During an interview on 8/10/2023, at 10:38 a.m., the QA stated MD 1’s name on Patient 2’s medical documents was a result of a mistake and a computer glitch. The QA stated they noticed the mistake on 8/10/2023, when MD 1 called the HHA to inform them he was not the doctor taking care of Patient 2. The QA stated no one had spoken to Patient 2’s PMD 4. During an interview on 8/10/23, at 10:45 a.m., the ADM stated the HHA staff needed to be more attentive in ensuring the correct doctor was documented in the patients’ (in general) records. During an interview on 8/10/2023, at 10:53 a.m., the DPCS stated she contacted the Quality Assurance (QA) to instruct her how to contact Patient 2’s PMD 4 to clarify the order written on the GACH’S discharge documents regarding checking Patient 2’s blood sugar level. The DPCS stated there was no response from PMD 4 and no further attempts were made to contact Patient 2’s PMD 4. During the concurrent interview on 8/10/2023, at 10:53 a.m., the DPCS stated she could not remember the name of the doctor she called, and there was no response from the doctor. The QA stated there were no further attempts made to contact Patient 2’s PMD 4. During an interview on 8/10/2023, at 11:03 a.m., the DPCS stated the risk of not monitoring Patient 2’s blood sugar levels were risk of hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels), both if left untreated, could cause a coma (loss of consciousness), and result in re-hospitalization and/or death. During an interview on 8/10/2023, at 11:07 a.m., the DPCS stated she had reviewed the GACH’s discharge summary documentation prior to visiting Patient 2. The DPCS stated she noticed there were instructions to check Patient 2’s blood sugar levels, documentation on diabetic meals, but no diabetic medications listed, which raised a “red flag.” The DPCS stated she should have followed up to make sure PMD 4 was contacted and notified. During a concurrent interview and record review on 8/10/2023, at 11:07 a.m., Patient 2’s record titled, “Reason for Assessment: Start of Care,” dated 8/8/2203, was reviewed with the DPCS. The record indicated Patient 2 did not have diabetes. The DPCS stated the reason she indicated Patient 2 did not have diabetes was because the GACH’s discharge summary documentation did not list any diabetic medications. The DPCS stated she questioned the document because it indicated to take blood sugar level samples and there was diabetic documentation pertaining to diabetic meals. The DPCS stated she should have followed up to make sure the doctor was notified. During an interview on 8/10/2023, at 11:15 a.m., the DPCS stated she completed the comprehensive assessment on 8/8/2023 (24 days after the SOC date on 7/15/2023). During an interview on 8/10/2023, at 11:22 a.m., the DPCS stated the comprehensive assessment and plan of care were done on 8/8/2023. During an interview on 8/10/2023, at 11:22 a.m., the DPCS stated there was no doctor managing and or overseeing the care of Patient 2 since the start of care on 7/15/2023. A review of Patient 2’s record titled, “Nursing Progress Note,” dated 8/11/2023, indicated a random blood sugar level of 274 mg/dl. Patient 4’s blood sugar levels indicated Patient 4 was experiencing hyperglycemia. During an interview on 8/11/2023, at 10 a.m., the Administrator (ADM) stated Patient 2’s PMD 4 was contacted on 8/10/2023 to clarify Patient 2’s orders. During an interview on 8/11/2023, at 1:30 p.m., the ADM stated Patient 2’s comprehensive assessment was supposed to be completed within 48 hours to one week after the start of care. The ADM stated the comprehensive assessment was important for the proper care planning and care of Patient 2. The ADM stated not completing the comprehensive assessment in a timely manner was a delay of care. The ADM stated nurses (in general) would not know how to care for Patient 2. ADM stated If there was no assessment there was no care plan. A record review of Patient 2’s document titled, “Home Health Certification and Plan of Care,” for certification period 7/15/23-9/12/23, did not indicate a treatment plan to monitor Patient 2’s blood sugar levels and manage his diabetes. Further review of the record indicated the DPCS had completed the document on 8/8/2023, at 8:33 p.m., twenty-four (24) days after the SOC date on 7/15/23. A review of facility’s policy and procedure titled, “Initial and Comprehensive Assessment” revised 4/2021, indicated “An initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse…The initial assessment visit must be performed either within 48 hours of the… start of care date… A comprehensive patient assessment will be completed within five (5) calendar days of the patients start of care.” A review of facility’s form titled “Registered Nurse – Job Title/Position” revised 4/2021, indicated “Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment…”

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure the comprehensive assessment (a tool used by nurses to evaluate a patient's complete health status) accurately reflected the patient's health status for one of eight sampled patients (Patient 5). This failure resulted in the delay of the development of an individualized plan of care (POC) based on care needs and management of Patient 5’s health status. Findings: A review of Patient 5’s medical record form titled “Patient Profile by Episode,” indicated a Start of Care (SOC) date of 12/8/2022, with diagnoses including Diabetes Mellitus type 2 (DM, a medical condition characterized by the body's inability to regulate blood sugar) and Hypertension (high blood pressure). A review of Patient 5’s Hospital 1 (H1) “Emergency Department Report,” dated 1/24/2023, indicated Patient 5 had “Coded Allergies: Penicillin (medication to treat infection) …” A review of Patient 5’s medical record titled “History and Physical,” dated 5/11/2023, indicated “code status DNR/DNI (do not resuscitate/do not intubate [when a healthcare provider inserts a tube through a person's mouth or nose, then down into their airway/windpipe]); Medication/allergies reviewed and updated; 1+ pitting edema (excess fluid builds up in the body, causing swelling) to bilateral (both) lower extremities (from the hip to the toes). A review of Patient 5’s medical record titled “Recertification (follow-up) assessment,” dated from 6/6/2023 to 8/4/2023, indicated under section “Advance Directive (a written instruction, such as a living will) – Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive); Functional Limitations – paralysis (the loss of the ability to move); Bathing: unable to use the tub/shower; No known allergies,” and no indication listed regarding low back pain on the “Active Diagnoses.” A review of Patient 5’s medical record titled “Recertification (follow-up) assessment,” dated from 8/5/2023 to 10/3/2023 that was provided on 8/9/2023, at 12 p.m., indicated under section “Advance Directive – Full Code Functional Limitations – paralysis; Bathing: unable to use the tub/shower; Allergic to penicillin,” and no indication listed regarding back pain on the “Active Diagnoses.” During a home visit observation and an interview on 8/9/2023, at 10 a.m., with Licensed Vocational Nurse 1 (LVN1) inside Patient 5’s residence at the Assisted Living Facility (ALF, a home for people who need help with daily care, but not as much help as a nursing home), Patient 5 was in his room sitting on a wheelchair by the side of his bed. Patient 5 stated he was “healthy,” but had back pain. Patient 5 stated he had back pain for almost a year and his legs were swollen. Patient 5 was able to stand up from a sitting position to demonstrate where his back pain was, able to sit back down without assistance. Patient 5 also stated he used a stool (plastic seat) to sit on while he showered himself in the shower. During a concurrent interview and record review on 8/10/2023, at 3:26 p.m., with the Director of Patient Care Services (DPCS) of Patient 5’s Electronic Medical Record (EMR), the DPCS stated Patient 5’s last History and Physical (H&P) was conducted on 5/11/2023, indicating Patient 5 was a DNR. DPCS stated it was important to know Patient 5’s status because if the opposite was performed it could go against Patient 5’s wishes. DPCS stated “It is considered a patient rights issue because we did not carry out the patient’s wishes.” During a concurrent interview and record review on 8/10/2023, at 3:45 p.m., with the DPCS of Patient 5’s EMR, the DPCS was unable to locate a skilled nurse assessment of Patient 5’s lower extremities edema or back pain. DPCS stated the EMR indicated Patient 5’s status was a full code and had no known allergies. DPCS stated, “Patient was not assessed thoroughly…” DPCS stated Patient 5’s H&P indicated +1 pitting edema to bilateral lower extremities. DPCS stated the Recertification Follow up assessment dated 8/5/2023, should read no known allergies. DPCS stated that they needed to clarify if the patient had any allergies. During a concurrent interview and record review on 8/10/2023, at 4:16 p.m. with DPCS of Patient 5’s EMR, the DPCS stated Patient 5's back pain was not addressed by the nurse (unidentified). The DPCS stated there was no documentation addressing Patient 5 back pain in his comprehensive assessment. DPCS stated, “The assessment, a full assessment was not done. The patient could end up with severe back injury and end up in the hospital.” A review of facility’s policy and procedure titled, “Initial and Comprehensive Assessment” revised 4/2021, indicated “The assessment will be patient-specific and comprehensive… During the initial and comprehensive nursing patient assessment, all baseline date to be used in measuring the patients progress toward goals and other relevant information will be documented in the patient clinical record…” A review of facility’s policy and procedure titled “Reassessment/Recertification” revised 4/2021, indicated “A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress toward outcomes.”

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to review and document all the current medications for four of eight sampled patients (Patients 1, 2, 5, and 6). This deficient practice placed Patients 1, 2, 5, and 6 at risk to experience adverse drug reactions (unintended, harmful events attributed to the use of medication). Findings: 1. A review of Patient’s 1's “Patient Profile,” indicated a start of care on 1/20/2023, with diagnoses including chronic (persisting for a long time or constantly recurring) pain. During a concurrent observation and interview of the home visit on 8/10/2023, at 12:26 p.m., the Director of Patient Care Services (DPCS) was observed reviewing the medications Patient 1 was taking and comparing them to a medication list. The following medications were not listed in Patient 1’s medication list: a. Zyrtec (an allergy medication) 10 milligrams (mg, a unit of measurement) tablet. During the concurrent observation and interview on 8/1/10/2023, at 12:26 pm, Patient 1 stated she was currently taking one Zyrtec pill a day since “months ago.” Patient 1 stated the medication was an over-the-counter medication (prescription not needed). b. Multivitamin (a supplement) one tablet once a day. During the concurrent observation and interview on 8/1/10/2023, at 12:26 pm, Patient 1 stated she was currently taking one multivitamin a day for three months. c. Tylenol (pain reliever) 500 mg, one tablet once a day. During the concurrent observation and interview on 8/1/10/2023, at 12:26 pm, Patient 1 stated she was currently taking Tylenol for pain relief since “many years ago.” d. Fish Oil (a supplement), one capsule daily. During the concurrent observation and interview on 8/1/10/2023, at 12:26 pm, Patient 1 stated she was currently taking fish oil for years. e. Vitamin B-12 (a supplement) one tablet daily. During the concurrent observation and interview on 8/1/10/2023, at 12:26 pm, Patient 1 stated she was currently taking vitamin B-12 for years. During a concurrent interview and record review on 8/10/2023, at 12:30 p.m., Patient 1’s record titled, “Patient Medication Profile,” with a printed date 8/8/2023, was reviewed by the DPCS. DPCS stated the record indicated “Metoprolol (a blood pressure medication) …50 mg tablets every 12 hours.” Patient 1 stated she started taking one tablet a day since March of 2023 because the doctor (unidentified) instructed her to do so. The DPCS stated to Patient 1 to talk to the doctor (unidentified) so the doctor (unidentified) could clarify the medication she was taking. During an interview on 8/10/2023, at 12:45 p.m., the DPCS stated Patient 1’s medication profile list was not updated to reflect the current medications Patient 1 was taking. The DPCS stated the nursing staff (in general) who visited Patient 1 needed to review during each home visit the medication labels and compare with the medication list to ensure the medications matched. The DPCS stated it was important to check for medication changes to help identify any possible complication. 2. A review of Patient’s 2 “Patient Profile,” indicated a start of care (SOC) on 7/15/2023, with diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure) without heart failure. During a concurrent observation and interview of the home visit on 8/10/2023, at 10:53 a.m., the DPCS was observed reviewing Patient 2’s current medications. A bottle of Allopurinol (unidentified dosage, a medication used to treat gout [sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints]) was observed in Patient 2’s home and DPCS stated the Allopurinol was not listed in the medication profile. Patient 2’s caregiver (PCG) stated she was not sure if Patient 2 was taking Allopurinol. The DPCS stated to the PCG to ask Patient 2’s Primary Medical Doctor 4 (PMD 4) if Patient 2 needed to continue taking Allopurinol or not. The DPCS stated to the PCG to take all the medications patient had at home to the doctor’s office and clarify which medications to take. During a concurrent observation and interview of the home visit on 8/10/2023, at 11:00 a.m., the DPCS was observed reviewing the medications Patient 2 was taking. Three bottles of Benazepril (a medication used to treat high blood pressure) of 40 mg were observed inside Patient 2’s home. Patient 2 stated he was taking Benazepril one tablet daily. The DPCS was observed reviewing the General Acute Care Hospital (GACH) discharge summary and stated the document indicated for Patient 2 to take Benazepril 20 mg tablet once daily. The DPCS told Patient 2 and the PCG to tell PMD 4 if he wanted Patient 2 to continue taking Benazepril 20 mg or 40 mg. The DPCS told PCG to take the GACH discharge summary medication list and medications to the doctor (PMD 4). During a concurrent observation and interview of the home visit on 8/10/2023, at 11:05 a.m., the DPCS was observed reviewing the medications Patient 2 was taking. Patient 2 stated he was taking magnesium (a supplement) 250 mg two times a day. The DPCS stated the magnesium was not in the medication profile. The DPCS told Patient 2 to clarify all the medications with PMD4 on his next scheduled appointment (unidentified time and date). 3. A review of Patient 5’s medical record form titled “Patient Profile by Episode,” indicated Patient 5 had a Start of Care (SOC) date of 12/8/2022 with diagnoses including Diabetes Mellitus type II (high blood sugar) and Hypertension (high blood pressure). A review of Patient 5’s undated medical record titled “Patient Medication Profile,” indicated medications on the list included: a. Docusate (a stool softener) 100 mg b. Multivitamin (supplement) c. Vitamin D3 (supplement) A review of Patient 5’s undated medical record titled, “Central ordered Medication and Destruction Record,” at the Assisted Living Facility’s (ALF) indicated there was no documentation of medications: Docusate, Multivitamin, or Vitamin D3 listed. During a joint home visit on 8/9/2023, at 11:20 a.m., with License Vocational Nurse 1 (LVN1) to Patient 5’s Assisted Living Facility (ALF), LVN1 completed a medication review using the HHA medication list and Patient 5’s medication bottles. LVN1 was unable to locate Docusate, Multivitamin, and Vitamin D3 medication bottles. The ALF Medication Nurse (MN) stated Patient 5 did not receive Docusate, Multivitamin, or Vitamin D3. LVN 1 stated Patient 5’s blood sugar levels were not checked. LVN1 stated she would call the HHA to inform them of the following discrepancies found: a. A Review of Patient 5’s medication list, indicated for Patient 5 to take Ibuprofen (medication for pain relief) 200 mg one tablet by mouth every six hours as needed for mild pain. For Patient 5 to take two tablets (400mg) for moderate pain. b. A review of Patient 5’s Medication Bottle indicated for Patient 5 to take Ibuprofen 200mg one tablet by mouth every six hours as needed for pain. c. A Review of Patient 5’s medication list, indicated for Patient 5 to take Carvedilol (medication to help control blood pressure) 25 mg one tablet by mouth every day and evening and to hold if Patient 2’s systolic blood pressure (SBP measures the pressure in the arteries when the heart beats) was below 110 millimeters of mercury (mm/Hg, a measurement of pressure) or heart rate below 60 beats per minute. d. A review of Patient 5’s Medication Bottle indicated for Patient 5 to take Carvedilol 25mg one tablet by mouth twice a day. e. A Review of Patient 5’s medication list, indicated for Patient 5 to take Finasteride (medication to treats benign [not harmful in effect] prostate [male gland] enlargement) 5 mg one tablet by mouth every night at bedtime. f. A review of Patient 5’s Medication Bottle indicated for Patient 5 to take Finasteride 5mg one tablet by mouth at bedtime and to wear gloves when handling the medication. g. A Review of Patient 5’s medication list, indicated for Patient 5 to take Hydrochlorothiazide (medication to help treat high blood pressure and fluid retention) 12.5mg one tablet by mouth every Monday, Wednesday, and Friday and to hold if Patient 5’s SBP was below 110 mm/Hg. h. A review of Patient 5’s Medication Bottle indicated for Patient 5 to take Hydrochlorothiazide 12.5mg one capsule by mouth every Monday, Wednesday, and Friday for hypertension and to hold if Patient 5’s blood pressure was below 110 mm/Hg. i. A Review of Patient 5’s medication list, indicated for Patient 5 to take Nortriptyline (medication used for treating nerve pain) 10 mg one tablet by mouth once daily. j. A review of Patient 5’s Medication Bottle indicated for Patient 5 to take Nortriptyline 10mg one capsule by mouth at bedtime for depression (a mood disorder marked by varying degrees of sadness). k. A Review of Patient 5’s medication list, indicated for Patient 5 to take Pepcid (medication to help prevent and relieve heartburn) 40 mg one table by mouth once daily. l. A review of Patient 5’s Medication Bottle indicated for Patient 5 to take Famotidine (medication to help prevent and relieve heartburn) 40 mg one tablet by mouth in the morning before breakfast for gastroesophageal reflux disease (GERD, a digestive disorder). During a concurrent interview and record review on 8/10/2023, at 4:09 p.m. with the DPCS of Patient 5’s Electronic Medical Record (EMR), the DPCS stated that medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) should be done at every visit to prevent overdose of medication. DPCS stated the medication labels needed to match the medication list and the ordered parameters should be followed. 4. A review of Patient 6’s medical record form titled “Patient Profile by Episode,” indicated Patient 6 had a Start of Care (SOC) date of 7/8/2023, diagnoses including hypertension (high blood pressure) and diabetes mellitus Type 2 (a medical condition characterized by the body's inability to regulate blood sugar levels). A review of Patient 6’s medical record titled “Home Health Certification and Plan of Care,” dated from 7/8/2023 to 9/5/2023, indicated “Skilled Nurse frequency visits once a week for nine weeks, reassess on the ninth week.” A review of Patient 6’s medical record titled “Patient Medication Profile” dated 7/8/2023, indicated for Patient 6 to take: a. Metformin (medication to treat blood sugar levels) 500 mg one tablet by mouth (PO) BID (twice a day) b. Amlodipine (medication to treat high blood pressure) 5/160 mg one tablet PO qhs (at bedtime) c. Kava-Kava (medication to help relax) 200mg one tab PO prn (as needed) for anxiety (nervousness, agitation, restlessness). During a telephone interview on 8/9/2023, at 3 p.m., with Patient 6’s Care Giver (PCG), the PCG stated Patient 6 was currently taking: a. Ativan/Lorazepam (medication to help treat anxiety) 0.5mg one tablet PO TID (three times per day) as needed for anxiety. b. Catapres (medication to help treat high blood pressure) 0.1 mg one tablet TID as needed for SBP higher 160 mm/Hg. c. Metformin 500mg one tablet PO BID. d. Amlodipine 5/160mg one tablet PO every morning. During the concurrent telephone interview on 8/9/2023, at 3 p.m., PCG stated, “The Ativan and Catapres were added by the doctor (unidentified) last month (July 2023) and I just received the medications two weeks ago (unidentified date).” During an interview on 8/10/2023 at 10:49 a.m., with the Administrator (ADM), the ADM stated the registered nurses (in general) and the quality assurance staff were responsible for reviewing and revising the patients’ (in general) medication lists. ADM stated the medication list needed to be reviewed and revised “whenever there are changes on recertification, and at every visit.” During an interview on 8/10/2023, at 4:09 p.m., with the DPCS, the DPCS stated the medication reconciliation was done at every visit and when the patient had a doctor’s visit. DPCS stated the patients’ (in general) medical records needed to be updated to prevent errors. DPCS stated the medication labels needed to match the medication list and if there were parameters the licensed nurses (in general) needed to follow. During an interview on 8/11/2023, at 11 a.m., with the ADM, the ADM stated “The reconciliation should be done at every visit. They have the medication sheets and the physical medication you compare one by one, the five rights. It is important to have a current updated medication list to avoid any medication errors.” A review of facility’s policy and procedure titled, “Medication Profile,” with a revised date of 4/2021, indicated “Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.”

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure a Registered Nurse (RN, in general) updated the comprehensive assessment for the recertification period for five of eight sampled patients (Patients 1, 4, 5, 6, and 8). This failure had the potential to result in a decline in the health status of Patients 1, 4, 5, 6, and 8. Findings: 1. A review of Patient’s 1 “Patient Profile” indicated a start of care on 1/20/23, with diagnoses including chronic (persisting for a long time or constantly recurring) pain. During a concurrent interview and record review on 8/11/2023, at 1:26 p.m., the Administrator (ADM) stated Patient1’s record titled, “Recertification (follow up) assessment, dated 8/8/2023 indicated Patient 1’s assessment was for certification period 7/19/2023 to 9/16/2023. The ADM stated Patient 1’s updated assessment was completed on 8/8/2023 and was considered late. The ADM stated the comprehensive assessment was supposed to be completed within 48 hours to one week from the beginning of the recertification date. The ADM stated the comprehensive assessment was important for the proper care planning and care of the patients (in general). The ADM stated the risk of not completing the comprehensive assessment in a timely manner was a delay of care. The ADM stated the licensed nurses (in general) would not know how to care for the patients (in general) and not able create a care plan if there was no comprehensive assessment. A review of Patient 1’s record titled “Home Health Certification and Plan of Care”, for certification period 7/19/2023-9/16/2023, indicated the care plan was done on 8/8/23023 at 10:48 p.m. The record indicated a skilled nurse was to visit Patient 1 once a week for nine weeks. 2. A review of Patient 4’s “Patient Profile,” indicated a start of care date of 9/7/2022, with diagnoses including Type 2 diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels). During a concurrent interview and record review on 8/11/2023, at 1:23 p.m., Patient 4’s record titled, “Recertification (Follow up) assessment,” dated 7/10/23 was reviewed with the ADM. The ADM stated the record indicated the assessment was for the certification period 7/4/2023-9/1/2023. The ADM stated the record did not indicate a signature and date of the nurse (unidentified) who completed the assessment. The ADM stated Patient 4’s updated assessment was completed on 7/10/2023 and was considered late because the assessment needed to be completed by 7/8/2023. The ADM stated she did not know why the nurse (unidentified) did not sign the document. The ADM stated the assessment should have not been considered completed without the nurse’s signature and date. The ADM stated the comprehensive assessment was important for the proper care planning and for the care of the patients (in general). A review of Patient 4’s record titled “Home Health Certification and Plan of Care,” for certification period 7/4/2023-9/1/2023, indicated the care plan was done on 8/8/2023 at 11:01 p.m. The record indicated a skilled nurse was to visit the patient once a week for nine weeks. 3. A review of Patient 5’s medical record form titled “Patient Profile by Episode” indicated Patient 5 had a Start of Care (SOC) date of 12/8/2022, with diagnoses including diabetes type 2 and hypertension (high blood pressure). A review of Patient 5’s medical record titled “Recertification (follow-up) assessment” dated from 6/6/2023 to 8/4/2023, provided on 8/8/2023, indicated the assessment was completed on 6/13/2023. 4. A review of Patient 6’s medical record form titled “Patient Profile by Episode” indicated Patient 6 had a Start of Care (SOC) date of 7/8/2023, diagnoses including hypertension and Type 2 diabetes. A review of Patient 6’s medical record titled “Recertification (follow-up) assessment” dated from 7/8/2023 to 9/5/2023, provided on 8/9/2023, indicated the assessment was completed on 7/14/2023. 5. A review of Patient 8’s medical record form titled “Patient Profile by Episode” indicated Patient 8 had a Start of Care (SOC) date of 3/29/2023, with diagnoses including Type 2 diabetes and hypertension. A review of Patient 8’s medical record titled “Recertification (follow-up) assessment” dated from 7/27/2023 to 9/24/2023, provided on 8/9/2023, indicated the assessment was completed on 8/8/2023. A review of facility’s policy and procedure titled, “Initial and Comprehensive Assessment” revised 4/2021, indicated “A comprehensive patient assessment will be completed within five (5) calendar days of the patients start of care… and at the following defined intervals thereafter: for recertification within the last five (5) das of every 60-day episode…” A review of facility’s policy and procedure titled “Reassessment/Recertification” revised 4/2021, indicated “The comprehensive assessment must be updated and revised every second calendar month, beginning with the start of care. The total plan of care must be renewed at least every 60 days.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation for Care Planning, Coordination, Quality of Care was met as follows: 1.The HHA failed to ensure an individualized Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative) was developed for six of eight sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 6, and Patient 8). (Refer to G 572). 2. The HHA failed to include information required in the Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative) for two of eight sampled patients (Patient 1 and Patient 2). - Patient 1’s POC did not have parameters/information for calling the doctor. - Patient 2’s POC did not have patient specific interventions and goals for managing his diabetes. (Refer to G 574). 3. The HHA failed to provide blood sugar monitoring as ordered by the physician for three of eight sampled patients (Patient 4, Patient 5, and Patient 6). (Refer to G 580). 4. The HHA failed to inform one of eight sampled patients' (Patient 6) primary physician that the patient was not having his blood sugar monitored/assessed as ordered. (Refer to G 590). 5. The HHA failed to ensure the physician was notified for one of eight sampled patients (Patient 4) when the respiratory rate was outside the ordered parameters. (Refer to G 602). 6. The HHA failed to ensure three of eight sampled patients (Patient 4 , Patient 5, and Patient 6) and their representatives receive ongoing education as specified in their Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative). - Patient 4 did not receive education on the signs and symptoms or hyper (high)/hypo (low) glycemia (blood sugar) - Patient 5 did not receive education on the signs and symptoms or hyper (high)/hypo (low) glycemia (blood sugar) - Patient 6 did not receive education on the signs and symptoms or hyper (high)/hypo (low) glycemia (blood sugar) (Refer to G 610). 7. The HHA failed to provide written information regarding the Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patient's representative) to two of eight sampled patients (Patient 2 and Patient 5). (Refer to G 612). 8. The HHA failed to ensure two of eight sampled patients (Patient 5 and Patient 6) or their representatives had their current medication list. (Refer to G 616). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure an individualized Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative) was developed for six of eight sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 6, and Patient 8). This failure resulted in the HHA not being able to create a comprehensive plan of care based upon the needs identified during the assessment and services needed to meet the patient's clinical needs and quality of care. Findings: During an interview on 8/8/2023, at 3:25 p.m., the Quality Assurance (QA) stated that Patients 1, 2, 5, 6, and 8 did not have a current Home Health Certification and Plan of Care (POC). The QA stated that Patient 6’s POC was not completed. QA stated that the POC was supposed to be completed within five days of certification or recertification and it is the plan of treatments based on the patient needs. QA stated that the visiting nurse was verbally made aware what the patient needs for treatment are and that their needs are based on the narrative notes completed by the RN (registered nurse) documented. QA stated that this was not best practice. QA stated that the visiting nurse communicated with the HHA via their cell phone if they don’t have a current POC on hand. a. A review of Patient 1's “Patient Profile” indicated, a start of care (SOC) date of 1/20/2023 with diagnoses including chronic pain. During a concurrent interview and record review on 8/11/2023, at 1:26 p.m., Patient 1’s record titled, “Recertification (Follow up) assessment, dated 8/8/2023 was reviewed with the Administrator (ADM). The record indicated the assessment was for certification period 7/19/2023 to 9/16/2023. The ADM stated Patient 1’s updated assessment was completed on 8/8/2023 and was considered late. The ADM stated the comprehensive assessment was supposed to be completed within 48 hours to one week from the beginning of the recertification date. The ADM stated the comprehensive assessment was important for the proper care planning and care of the patients; the assessment drives the care plan. The ADM stated the risk of not completing the comprehensive assessment in a timely manner is delay of care. The ADM stated the nurse will not know how to care for the patient if there is no assessment and there is no care plan. A review of Patient1’s record titled “Home Health Certification and Plan of Care” for certification period 7/19/2023 to 9/16/2023, indicated the care plan was done on 8/8/2023 at 10:48 p.m. The record indicated a skilled nurse was to visit the patient once a week for nine weeks. Patient 1 did not have a plan of care from 7/19/2023 to 8/8/2023. The skilled nurse was providing care without being aware of the patient’s treatment plan, goals, and interventions. b. A review of Patient’s 2 “Patient Profile” indicated an SOC date of 7/15/2023 with diagnoses including hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 8/8/2023, at 3:23 p.m., Patient 2’s medical records were reviewed with the Quality Assurance staff (QA). There was no plan of care (POC) in Patient 2’s record. The QA stated the POC was supposed to be done within five days of the start of care, but staff were swamped and could not complete the POC. The QA stated the purpose of the POC was the plan of treatment, tells the staff what needs to be assessed, education needed to be provided, reportable conditions, and who needs to be contacted in case of an emergency. During an observation of the home visit on 8/9/2023, at 10:15 a.m., the Director of Patient Care Services (DPCS) was observed providing care to Patient 2 without a completed POC in the clinical record. During an interview on 8/9/2023, at 10:30 a.m., the PCG mentioned to the DPCS, Patient 2 was a diabetic (a person whose blood sugar is high). During an interview on 8/10/2023, at 11:07 a.m., the DPCS stated she had reviewed the GACH’s discharge summary documentation prior to visiting the Patient 2. The DPCS stated she noticed there were instructions to check the blood sugar levels, documentation on diabetic meals, but no diabetic medications listed, which raised a “red flag”. During an interview on 8/10/2023, at 11:22 a.m., the DPCS stated the comprehensive assessment and plan of care were done on 8/8/2023. A record review of Patient 2’s document titled, “Home Health Certification and Plan of Care”, for certification period 7/15/2023 to 9/12/2023, the POC failed to identify treatment plan to monitor Patient 2’s blood sugar levels and manage his diabetes (a chronic health condition characterized by elevated levels of blood sugar). Further review of the record indicated the DPCS had completed the document on 8/8/2023 at 8:33 p.m., three weeks and three days after the start of care. c. A review of Patient’s 4's “Patient Profile” indicated an SOC date of 9/7/2022, with diagnoses including Type 2 diabetes (high levels of sugar in the blood, a chronic condition). During a concurrent interview and record review on 8/11/2023, at 1:23 p.m., Patient 4’s record titled, “Recertification (Follow up) assessment, dated 7/10/2023 was reviewed with the ADM. The record indicated the assessment was for certification period 7/4/2023 to 9/1/2023. Further review of the record did not indicate a signature and date of the nurse who completed the assessment. The ADM stated Patient 4’s updated assessment was completed on 7/10/2023 and was considered late because it should have been completed by 7/8/2023. The ADM stated she did not know why the nurse did not sign the document. The assessment should have not been considered completed without the nurse’s signature and date. The ADM stated the comprehensive assessment was important for the proper care planning and care of the patients; the assessment drives the care plan. A review of Patient 4’s record titled “Home Health Certification and Plan of Care”, for certification period 7/4/2023 to 9/1/2023, indicated the care plan was done on 8/8/2023 at 11:01 p.m. The record indicated a skilled nurse was to visit the patient once a week for nine weeks. Patient 4's clinical record did not have a plan of care from 7/4/2023 to 9/1/2023. The skilled nurse was providing care without being aware of the patient’s treatment plan, goals, and interventions. d. A review of Patient 5’s medical record form titled “Patient Profile by Episode”, indicated Patient 5 had an SOC date of 12/8/2022 with diagnoses including Diabetes Mellitus type II (high blood sugar) and hypertension (high blood pressure). A review of Patient 5’s medical record titled “Recertification (follow-up) assessment” dated from 6/6/2023 to 8/4/2023, was provided to the Department representative (surveyor) on 8/8/2023. Due to the delay in completing an updated comprehensive assessment, Patient 5 did not have a plan of care from 6/6/23 to 8/4/23. The skilled nurse was providing care without being aware of the patient’s treatment plan, goals, and interventions. e. A review of Patient 6’s medical record form titled “Patient Profile by Episode”, indicated Patient 6 had an SOC date of 7/8/2023 with diagnoses including hypertension (high blood pressure) and Diabetes Mellitus type II (high blood sugar). A review of Patient 6’s medical record titled “Recertification (follow-up) assessment” dated from 7/8/2023 to 9/5/2023, was provided to the surveyor on 8/9/2023. Due to the delay in completing an updated comprehensive assessment, Patient 6 did not have a plan of care from 7/8/23 to 8/8/2023. The skilled nurse was providing care without being aware of the patient’s treatment plan, goals, and interventions. f. A review of Patient 8’s medical record titled “Patient Profile by Episode”, indicated Patient 8 had an SOC date of 3/29/2023 with diagnoses including Diabetes Mellitus type II (high blood sugar) and hypertension (high blood pressure). A review of Patient 8’s medical record titled “Recertification (follow-up) assessment” dated from 7/27/2023 to 9/24/2023, was provided to the surveyor on 8/9/2023. Due to the delay in completing an updated comprehensive assessment, Patient 8 did not have a plan of care from 7/27/23 to 8/8/2023. The skilled nurse was providing care without being aware of the patient’s treatment plan, goals, and interventions. A review of facility’s policy and procedure, titled “Initial and Comprehensive Assessment” and revised 4/2021, indicated “A comprehensive patient assessment will be completed within five (5) calendar days of the patients start of care… and at the following defined intervals thereafter: for recertification within the last five (5) days of every 60-day episode…” A review of facility’s policy and procedure, titled “Reassessment/Recertification” and revised 4/2021, indicated “The comprehensive assessment must be updated and revised every second calendar month, beginning with the start of care. The total plan of care must be renewed at least every 60 days…” A review of facility’s policy and procedure, titled “Care Planning Process” and revised 4/2021, indicated “The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient.” A review of facility’s form, titled “Registered Nurse – Job Title/Position” and revised 4/2021, indicated “Initiates the plan of care… develops a care plan…”

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 observation, interview, and record review, the Home Health Agency (HHA) failed to include information required in the Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative) for two of eight sampled patients (Patient 1 and Patient 2). - Patient 1’s POC did not include when to call the doctor for any significant changes of patient's condition. - Patient: 2’s POC did not have patient specific interventions and goals for managing his diabetes. This failure had the potential to result in patients not receiving the identified needs and services, which could lead to a decline in their health status and that could affect their quality of care and well-being. Findings: A review of Patient 1's “Patient Profile” indicated a start of care date (SOC) of 1/20/2023 with diagnoses including chronic pain. During a concurrent interview and record review on 8/11/2023, at 1:30 p.m., Patient 1’s record titled, “Home Health Certification and Plan of Care”, for certification period 7/19/2023 to 9/16/2023, was reviewed with the Administrator (ADM). The record did not indicate instructions on when to call the doctor for any significant changes of patient's condition. The ADM stated the information missing were parameters for heart rate, oxygen saturation (amount of oxygen in the blood), respiratory rate, and pain. The ADM stated it was important to include this information in the plan of care for proper assessment of the patient condition. The nurses needed the information to use the guideline parameters set for notification to the doctor when there is a change of condition. A review of Patient 2's “Patient Profile” indicated an SOC date of 7/15/2023 with diagnoses including hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 8/8/2023, at 3:23 p.m., Patient 2’s medical records were reviewed with the Quality Assurance staff (QA). There was no plan of care (POC) documented in Patient 2’s record. The QA stated the POC was supposed to be done within five (5) days of the start of care, but staff were swamped and could not complete the POC. The QA stated the purpose of the POC was the plan of treatment, tells the staff what needs to be assessed, education needed to be provided, reportable conditions, and who needs to be contacted in case of an emergency. During an observation of the home visit on 8/9/2023, at 10:15 a.m., the Director of Patient Care Services (DPCS) was observed providing care to Patient 2. The DPCS provided a plan of care to the department of public health representative on 8/9/2023. During an interview on 8/9/2023, at 10:30 a.m., the PCG stated to the DPCS, Patient 2 was a diabetic. A record review of Patient 2’s document titled, “Home Health Certification and Plan of Care”, for certification period 7/15/2023 to 9/12/2023, did not indicate a treatment plan to monitor Patient 2’s blood sugar levels and manage his diabetes. There was no patient specific interventions and measurable goals for Patient 2. A review of facility’s policy and procedure, titled “Care Planning Process” and revised 4/2021, indicated “Based on the assessment and conclusions, the plan of care will include, but not be limited to: all pertinent diagnoses…”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide blood sugar monitoring as ordered by the physician for three of eight sampled patients (Patient 4, Patient 5, and Patient 6). This failure had the potential to result in missed treatments, which could have placed the patient at risk for the development of hyper or hypoglycemia which could lead to death. Findings: a. A review of Patient’s 4 “Patient Profile” indicated a start of care (SOC) date of 9/7/2022, with diagnoses including Type 2 diabetes (high levels of sugar in the blood, a chronic condition). During a concurrent interview and record review on 8/11/2023, at 1:10 p.m., Patient 4’s record titled, “Plan of Care” for certification period 7/4/2023 to 9/1/2023, was reviewed with the Administrator (ADM). The record indicated a skilled nurse was to visit Patient 4 once a week for nine (9) weeks, instruct and teach about signs and symptoms of low sugar (hypoglycemia), high sugar (hyperglycemia) in the blood, and monitor the level of sugar in the blood. The ADM stated it was important for the nurse visiting Patient 4 to take a reading on the blood sugar level to make sure it was in the desired range as ordered by the doctor. The ADM stated it was important to teach the patient about the diabetes, so the patient knows how to manage the condition when the HHA staff are not there. The ADM stated if patient does not receive diabetes teaching, there can be complications of diabetes such as hypo and hyper glycemia, which can result in hospitalization. During a concurrent interview and record review on 8/11/2023, at 1:25 p.m., Patient 4’s record titled “Nursing Progress Note” for 7/7/2023, 7/14/2023, 7/21/2023, and 7/28/2023, was reviewed with the ADM. The ADM stated there was no blood sugar levels taken and no diabetes management education provided to Patient 4. The patient did not receive the services provided as indicated in the plan of care. b. A review of Patient 5’s medical record form titled “Patient Profile by Episode” indicated, Patient 5 had an SOC date of 12/8/2022 with diagnoses including Diabetes Mellitus type II (DMII - high blood sugar) and hypertension (high blood pressure). A review of Patient 5’s medical record titled “Home Health Certification and Plan of Care” dated from 6/6/2023 to 8/4/2023, indicated “Skilled nurse to perform observation/assessment of … blood sugar monitoring… Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer; Skilled nurse to report to MD of patients blood sugar (BS) of less than 80 mg/dl (mg/dl, milligram per deciliter, unit of measurement) or more than 300 mg/dl…”. A review of Patient 5’s Assisted Living Facility’s medical record titled, “Central ordered Medication and Destruction Record” indicated blood sugar level checks. During a joint home visit on 8/9/2023, at 11:20 a.m., with License Vocational Nurse 1 (LVN1) to Patient 5’s residence at the Assisted Living Facility (ALF), LVN1 completed a skilled nurse visit. The ALF Medication Nurse (MN) stated that Patient 5 has never had his blood sugar level checked while at the ALF. During a concurrent interview and record review on 8/10/2023 at 4:13 p.m. with the Director of Patient Care Services (DPCS) of Patient 5’s Electronic Medical Record (EMR), DPCS stated, “Patient’s diagnosis is type two DM, he has not been monitored for his DM. The patient will end up going in shock if his sugar is low or too high, which will require hospitalization.” c. A review of Patient 6’s medical record form, titled “Patient Profile by Episode”, indicated Patient 6 had an SOC date of 7/8/2023 with diagnoses including hypertension (high blood pressure) and Diabetes Mellitus type II (high blood sugar). A review of Patient 6's medical record titled “Home Health Certification and Plan of Care” dated from 7/8/2023 to 9/5/2023, indicated “Skilled nurse to perform observation/assessment of … all body systems emphasizing on … endocrine status… Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer, diabetic skin and foot care; Skilled nurse to report to MD of patients BS (blood sugar) of less than 80 mg/dl or more than 300 mg/dl…”. A review of Patient 6’s Electronic Medical Record (EMR) on 8/8/2023 at 10:02 p.m., indicated there was no documented evidence of Patient 6’s Fasting Blood Sugar (FBS) from 7/12/2023 to 7/29/2023. During a telephone interview on 8/9/2023 at 3 p.m., with Patient 6’s Care Giver (CG1), CG1 stated that Patient 6 was admitted on 7/8/2023 and has not received the glucometer (device to check the level of sugar in the blood) the HHA was to send. During a concurrent interview and record review on 8/11/2023, at 11 a.m., with the Administrator (ADM) of Patient 6’s EMR, the ADM stated that P6’s medical doctor ordered the glucometer and the HHAs responsibility was to call the pharmacy to check on it. While reviewing the EMR, ADM stated that no one has followed up on it. ADM sated it was important to educate patients on their POC, “so they know the management of their plan of care.” A review of facility’s policy and procedure, titled “Rights and Responsibilities” and revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: I. The organization shall ensure that the patient receives all services outlined in the plan of care.” A review of facility’s form, titled “Registered Nurse – Job Title/Position” and revised 4/2021, indicated “Communicates with the physician regarding the patients’ needs and reports any changes in the patient’s condition.”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to inform the primary physician promptly of the patient's blood sugar levels not being monitored as indicated in the POC for one of eight sampled patients (Patient 6). This failure resulted in HHA staff not able to determine any significant changes of the disease process which could lead to life threatening complications including death. Findings: A review of Patient 6’s medical record titled “Patient Profile by Episode”, indicated a start of care (SOC) date of 7/8/2023 with diagnoses including hypertension (high blood pressure) and Diabetes Mellitus type II (high blood sugar). A review of Patient 6’s medical record titled “Home Health Certification and Plan of Care” dated from 7/8/2023 to 9/5/2023, indicated “Skilled nurse to perform observation/assessment of … all body systems emphasizing on … endocrine status… Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer, diabetic skin and foot care; Skilled nurse to report to MD of patients BS (blood sugar) of less than 80 mg/dl or more than 300 mg/dl…”. A review of Patient 6’s Electronic Medical Record (EMR) on 8/8/2023 at 10:02 p.m., indicated there was nothing documented on Patient 6’s Fasting Blood Sugar (FBS) from 7/12/2023 to 7/29/2023. During a telephone interview on 8/9/2023 at 3:00 p.m., with Patient 6’s Care Giver (PCG), PCG stated that Patient 6 was admitted on 7/8/2023 and has not received the glucometer (device to check the level of sugar in the blood) the HHA was to send. During a concurrent interview and record review on 8/11/2023, at 11:00 a.m., with the Administrator (ADM) of Patient 6’s EMR, the ADM stated that Patient 6’s medical doctor ordered the glucometer and the HHAs responsibility was to call the pharmacy to check on it. While reviewing the EMR, ADM stated that no one has followed up on it. ADM sated that Patient 6’s MD has not been made aware that patient was not provided a glucometer in order to perform his blood sugar checks. A review of facility’s form, titled “Registered Nurse – Job Title/Position” and revised 4/2021, indicated “Communicates with the physician regarding the patients’ needs and reports any changes in the patient’s condition.” A review of facility’s policy and procedure, titled “Care Planning Process” and revised 4/2021, indicated “Clinicians will inform the patients physician of any changes that suggest a need to alter the plan of care.” A review of facility’s policy and procedure, titled “Safe and Appropriate Use of Medical Equipment and Supplies” and revised 4/2021, indicated “The Clinical Supervisor will establish a tracking mechanism to locate equipment used in the provision of care.”

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 HHA failed to ensure the physician was notified for one of eight sampled patients (Patient 4) when the respiratory rate was outside the ordered parameters. This failure resulted in the physician not being aware of the patients change in condition. Findings: A review of Patient’s 4's “Patient Profile” indicated a start of care date of 9/7/2022 with diagnoses including Type 2 diabetes (high levels of sugar in the blood, a chronic condition). During a concurrent interview and record review on 8/11/2023, at 1:10 p.m., Patient 4’s record titled “Home Health Certification and Plan of Care” for certification period 7/4/2023 to 9/1/2023 was reviewed with the Administrator (ADM). The record indicated the skilled nurse was to report to the doctor if Patient 4 was experiencing “labored breathing”. The ADM stated labored breathing meant a respiratory rate of over 20 breaths per minute. The ADM stated a normal breathing pattern was 16 to 20 breaths per minute. During a concurrent interview and record review on 8/11/2023, at 1:15 p.m., Patient 4’s record titled “Nursing Progress Note”, dated 6/23/2023, was reviewed with the ADM. The record indicated Patient 4’s respiratory rate was 29 breaths per minute. Further review of the record did not indicate the skilled nurse had notified the doctor as indicated in the POC. The ADM stated a respiratory rate of 29 breaths per minute required doctor notification because it indicates a change of condition, which requires further assessment. The ADM stated Patient 4’s doctor was not notified. A review of facility’s policy and procedure, titled “Care Planning Process” and revised 4/2021, indicated “Clinicians will inform the patients physician any changes that suggest a need to alter the plan of care.”

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure three of eight sampled patients (Patient 4 , Patient 5, and Patient 6) and or patient caregivers (PCG) receive ongoing education as specified in their Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative). - Patient 4 did not receive education on the signs and symptoms or hyper (high)/hypo (low) glycemia (blood sugar) - Patient 5 did not receive education on the signs and symptoms or hyper (high)/hypo (low) glycemia (blood sugar) - Patient 6 did not receive education on the signs and symptoms or hyper (high)/hypo (low) glycemia (blood sugar) This failure had the potential to prolong the patient’s recovery and extend their discharge date from HHA services. Findings: a. A review of Patient’s 4's “Patient Profile” indicated a start of care (SOC) date of 9/7/2022, with diagnoses including Type 2 diabetes (high levels of sugar in the blood, a chronic condition). During a concurrent interview and record review on 8/11/2023, at 1:10 p.m., Patient 4’s “Plan of Care” for certification period 7/4/2023 to 9/1/2023, was reviewed with the Administrator (ADM). The record indicated a skilled nurse was to visit Patient 4 once a week for nine (9) weeks, instruct and teach about signs and symptoms of low sugar (hypoglycemia) and high sugar (hyperglycemia) in the blood. The ADM stated it was important to teach the patient about the diabetes, so the patient knows how to manage the condition when the HHA staff are not there. If patient does not receive diabetes teaching, there can be complications of diabetes such as hypo and hyper glycemia, which can result in hospitalization. During a concurrent interview and record review on 8/11/2023, at 1:25 p.m., Patient 4’s “Nursing Progress Note” for 7/7/2023, 7/14/2023, 7/21/2023, and 7/28/2023, was reviewed with the ADM. The ADM stated there was no blood sugar levels taken and no diabetes management education provided to Patient 4. The patient did not receive the education as indicated in the plan of care. b. A review of Patient 5’s medical record titled “Patient Profile by Episode” indicated Patient 5 had an SOC date of 12/8/2022 with diagnoses including Diabetes Mellitus type II (DMII - high blood sugar) and hypertension (high blood pressure). A review of Patient 5’s medical record titled “Home Health Certification and Plan of Care” dated from 6/6/2023 to 8/4/2023, indicated “Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer; Skilled nurse to report to MD of patients BS (blood sugar) of less than 80mg/dl or more than 300 mg/dl…”. A review of Patient 5’s medical record at the Assisted Living Facility, titled “Central ordered Medication and Destruction Record,” indicated no blood sugar level checks. During a joint home visit on 8/9/2023, at 11:20 a.m. with License Vocational Nurse 1 (LVN 1) to Patient 5’s residence at the Assisted Living Facility (ALF), LVN 1 completed a skilled nurse visit. LVN 1 did not discuss the signs and symptoms of hyper and hypo glycemia with Patient 5. The ALF Medication Nurse (MN) stated that Patient 5 has never had his blood sugar level checked while at the ALF. During a concurrent interview and record review on 8/10/2023, at 4:13 p.m., with the Director of Patient Care Services (DPCS) of Patient 5’s Electronic Medical Record (EMR), DPCS stated, “Patient’s diagnosis is type two DM, he has not been monitored for his DM. The patient will end up going in shock if his sugar is low or too high, which will require hospitalization.” c. A review of Patient 6’s medical record titled “Patient Profile by Episode”, indicated Patient 6 had an SOC date of 7/8/2023 with diagnoses including hypertension (high blood pressure) and Diabetes Mellitus type II (high blood sugar). A review of Patient 6’s medical record titled “Home Health Certification and Plan of Care” dated from 7/8/2023 to 9/5/2023, indicated “Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer, diabetic skin and foot care.” During a telephone interview on 8/9/2023, at 3:00 p.m., with Patient 6’s Care Giver (PCG), PCG stated that Patient 6 was admitted on 7/8/2023 and has not received the glucometer (device to check the level of sugar in the blood) the HHA was to send. During a concurrent interview and record review on 8/11/2023, at 11:00 a.m., with the Administrator (ADM) of Patient 6’s EMR, the ADM stated it was important to educated patients on their POC, “so they know the management of their plan of care.” A review of facility’s policy and procedure, titled “Rights and Responsibilities” and revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: C. The goals of care, the interventions that support those goals, and the identification of the staff providing services.” A review of facility’s form, titled “Registered Nurse – Job Title/Position” and revised 4/2021, indicated “Provides health care instructions to the patient as appropriate per assessment and plan of care.”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide written information regarding the Plan of Care (POC – an individualized care plan developed by a support team using a person-centered approach that describes the services needed by the patient, and it also facilitates communication among members of the patients care team, the patient, and the patients representative) for two of eight sampled patients (Patient 2 and Patient 5). This deficient practice resulted in patients and their caregivers lack the knowledge to render care services to the patients as identified in the POC. A review of Patient’s 2's “Patient Profile” indicated a start of care (SOC) date of 7/15/2023, with diagnoses including hypertensive heart disease without heart failure (high blood pressure). During an observation of the home visit on 8/9/2023, at 10:26 a.m., an agency binder (information provided by the HHA regarding patient rights, plan of care, medication list, and information on resources) was observed. A plan of care was not observed in the agency binder. During an interview on 8/9/2023, at 10:26 a.m., Patient 2 stated he had not received a plan of care and did not know what that was. Patient 2 did not have information at home regarding his patient specific care. A review of Patient 5’s medical record titled “Patient Profile by Episode” indicated an SOC date of 12/8/2022 with diagnoses including Diabetes Mellitus type II (high blood sugar) and hypertension (high blood pressure). During a joint home visit on 8/9/2023, at 10 a.m., with License Vocational Nurse 1 (LVN 1) to Patient 5’s residence at the Assisted Living Facility (ALF), Patient 5 stated that the HHA folder was brought to his room this morning because they told him a surveyor was coming. Patient 5 stated that he did not know what was inside that folder because it was the first time he was seeing it. Patient 5 also stated that he was never provided with the State complaint number. During an interview on 8/11/2023, at 2:42 p.m., with the Administrator (ADM), the ADM stated that the HHA binder was provided and explained to all patients. ADM stated that it’s the patients right to know their care. A review of facility’s policy and procedure, titled “Rights and Responsibilities” and revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: D. The hours of care/service and how to obtain care/service after hours. J. The…frequency of visits… A review of facility’s policy and procedure, titled “Care Planning Process” and revised 4/2021, indicated “The organization shall provide the patient and caregiver with a copy of written instructions…”

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered 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 Home Health Agency (HHA) failed to ensure two of eight sampled patients (Patient 5 and Patient 6) or their caregivers had the current medication list. This failure resulted in the HHA staff lack of knowledge of the patient's current medication, treatment, the potential to result in missed medication doses, wrong medication administration, and delay in medication delivery. Findings: a. A review of Patient 5’s medical record titled “Patient Profile by Episode”, indicated a Start of Care (SOC) date of 12/8/2022 with diagnoses including Diabetes Mellitus type II (high blood sugar) and hypertension (high blood pressure). During a joint home visit on 8/9/2023, at 10:00 a.m., with License Vocational Nurse 1 (LVN 1) to Patient 5's residence at the Assisted Living Facility (ALF), Patient 5 stated that the HHA folder was brought to his room this morning because they told him a surveyor was coming. Patient 5 stated that he did not know what was inside that folder because it was the first time he was seeing it. During a joint home visit on 8/9/2023, at 11:20 a.m., with License Vocational Nurse 1 (LVN 1) to Patient 5’s residence at the Assisted Living Facility (ALF), LVN 1 completed a medication review using the HHA medication list and Patient 5’s medication bottles. ALF Medication Nurse (MN) stated that they have their own medication list for Patient 5, and that they do not have or use the HHA list. LVN 1 used the HHAs medication list and compared it to Patient 5’s medication bottles, with discrepancies found. LVN 1 stated she will call the HHA to inform them of discrepancies. b. A review of Patient 6’s medical record titled “Patient Profile by Episode”, indicated Patient 6 had an SOC date of 7/8/2023 with diagnoses including hypertension (high blood pressure) and Diabetes Mellitus type II (high blood sugar). A review of Patient 6’s medical record titled “Patient Medication Profile” dated 7/8/2023, indicated Patient 6 was prescribed: - Metformin (anti-diabetic medication) 500 milligrams (mg, a unit of mass), one tablet by mouth (PO) twice a day (BID) - Amlodipine (a medication used to treat high blood pressure) 5/160 mg, one tablet PO at bedtime (QHS) - Kava Kava (supplement) 200 mg, one tablet PO as needed (prn) for anxiety. During a telephone interview on 8/9/2023, at 3:00 p.m., with Patient 6’s Care Giver (PCG), PCG stated that Patient 6 was currently taking: - Ativan/Lorazepam 0.5 mg, one tablet PO three times per day (TID) as needed for anxiety - Catapres generic (a medication used to treat high blood pressure) 0.1 mg, one tablet TID as needed for systolic blood pressure (SBP, measures the pressure in the arteries when heart beats) below 160 - Metformin 500 mg, one tablet PO BID - Amlodipine 5/160 mg, one tablet PO every morning. PCG stated, “The Ativan and Catapres were added by the doctor last month, I just received the medications two weeks ago.” During an interview on 8/10/2023, at 10:49 a.m., with the Administrator (ADM), the ADM stated that the registered nurse and the quality assurance is responsible for reviewing and revising the patient’s medication list. ADM stated that the medication list is reviewed and revised “whenever there are changes on recertification, and at every visit”. During an interview on 8/10/2023, at 4:09 p.m., with the Director of Patient Care Services (DPCS), DPCS stated that the patients’ medical record needs to be updated to prevent errors. During an interview on 8/11/2023, at 11:00 a.m., with the Administrator (ADM), the ADM stated “The reconciliation should be done at every visit. They have the medication sheets and the physical medication you compare one by one, the five rights. It is important to have a current updated medication list to avoid any medication errors.” During an interview on 8/11/2023, at 2:42 p.m., with the Administrator (ADM), the ADM stated that the HHA binder is provided and explained to all patients. ADM stated that it’s the patients right to know their care. A review of facility’s policy and procedure, titled “Medication Profile” and revised 4/2021, indicated “During subsequent home visits, the medication profile will be used as a care planning and teaching guide…The medication profile and other relevant data will be available to all clinicians providing care.” A review of facility’s policy and procedure, titled “Rights and Responsibilities” and revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: C. The goals of care, A review of facility’s policy and procedure, titled “Care Planning Process” and revised 4/2021, indicated “The organization shall provide the patient and caregiver with a copy of written instructions…”

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Skilled Professional Services was met as follows: 1. The Home Health Agency (HHA) failed to ensure, a Registered Nurse (RN) conducted a Certified Home Health Aide (CHHA) supervisory visit (a personal visual observation of each facility staff by a Registered Nurse responsible for the care and services provided to the patients at home) to monitor and evaluate the CHHAs’ care with the patients at least every 14 days, and ensure an individualized patient plan of care was available to follow in providing care and services for the two of eight sampled patients, (Patient 6 and Patient 8). This failure had the potential to result in patient mistreatment, missed treatments, or inappropriate delivery of patient care which can affect the quality of care provided to all the patients under the agency’s care. (Refer to G702) 2. The HHA failed to ensure the established Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was provided to one of eight sampled patients, (Patient 6). This failure resulted in patient not receiving the care which had the potential to delay the healing process, could potentially cause complications that can affect the highest practicable well-being of the affected patient. (Refer to G704) 3. The HHA failed to ensure a Registered Nurse (RN) conducted the License Vocational Nurse (LVN) supervisory visit at least every 30 days, to monitor and evaluate the LVNs performance in the care and services provided to the four of eight sampled patients, (Patient 1, Patient 4, Patient 5, and Patient 8). This failure had the potential to result in a poor-quality patient care provided to the patients under the agency’s care. (Refer to G726) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Skilled Professional Services to ensure highest quality health care is provided to patients assessed to receive home health services. .

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health failed to ensure, a Registered Nurse (RN) conducted a Certified Home Health Aide (CHHA) Supervisory Visit (a personal visual observation of each facility staff by a Registered Nurse responsible for the care and services provided to the patients at home) to monitor and evaluate the CHHAs’ care with the patients at least every 14 days, and ensure an individualized patient plan of care was available to follow in providing care and services for the two of eight sampled patients, (Patient 6 and Patient 8). This failure had the potential to result in patient mistreatment, missed treatments, or inappropriate delivery of patient care which can affect the quality of care provided to all the patients under the agency’s care. A review of Patient 6’s medical record form titled “Patient Profile by Episode” indicated a Start of Care (SOC) date of 7/8/2023, with diagnoses including hypertension (high blood pressure) and diabetes mellitus type II (high blood sugar). A review of Patient 6’s Electronic Medical Record (EMR) on 8/8/2023 at 9:59 p.m., indicated the Certified Home Health Aide (CHHA) assignment sheet (AS – form filled out by a registered nurse which informs and guides the CHHA on the services and monitoring the patient requires) dated 7/7/2023 was left blank. It also indicated there was no documented CHHA care plan. During a concurrent interview and record review of Patient 6’s Electronic Medical Record (EMR), on 8/11/2023, at 11 a.m., with the Administrator (ADM), the ADM stated that Patient 6’s CHHA frequency was twice a week and that the Registered Nurse (RN) supervises the CHHA. ADM stated that an assignment sheet is formulated by the RN after they complete their assessment and is provided to the CHHA as a guidance on patient’s care. ADM stated Patient 6 did not have a supervisory visit or a CHHA assignment sheet. When asked, ADM stated, “without an assignment sheet, the CHHA does not know what to follow. They need to check that they are following the proper techniques and if the patient is bedbound or anything, we tell them precautions.” A review of Patient 8’s medical record form titled “Patient Profile by Episode” indicated a Start of Care (SOC) date of 3/29/2023, with diagnoses including diabetes mellitus type II and hypertension. A review of Patient 8’s Electronic Medical Record (EMR) on 8/8/2023, at 8:37 p.m., indicated there were three Certified Home Health Aide (CHHA) assignment sheet dated 5/27/2023, 6/22/2023, and 7/25/2023 were also blank and not completed by the RN. A review of Patient 8’s EMR on 8/8/2023, at 9:19 p.m., indicated there were three Certified Home Health Aide (CHHA) supervisory notes dated 6/19/2023, 7/11/2023, and 7/25/2023, that were not completed by the RN. During a concurrent interview and record review of Patient 8’s Electronic Medical Record (EMR), on 8/11/2023, at 12 p.m., with the ADM, the ADM stated that there were no CHHA supervisory visit notes and no completed CHHA assignment sheets in the EMR. A review of facility’s policy and procedure titled, “Supervision,” revised 4/2021, indicated, “A registered nurse will be available whenever home health aide services are provided. Home health aide services will be supervised every two (2) weeks. Licensed Vocational nurses will be supervised every 30 days.” A review of facility’s policy and procedure titled “Home Health Aide Plan of Care” revised 4/2021, indicated “Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide. The patients… appropriate skilled professional upon initialization of aide services will develop the written home health aide plan of care, consistent with the comprehensive plan of care and physician orders. The… clinician will directly supervise the home health aide at least every 14 days to ensure care is provided according to plan.” A review of facility’s policy and procedure titled, “Rights and Responsibilities” revised 4/2021, indicated “Supervisory visits with clinical disciplines will be conducted to ensure these rights are honored and protected according to organizational policy.” A review of facility’s policy and procedure titled, “Home Health Aide Supervisory Visits” revised 4/2021, indicated “The registered nurse… that is familiar with the patient, the patients plan of care, and the written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals. They must be conducted at least every fourteen (14) days…” A review of facility’s form titled “Registered Nurse – Job Title/Position” revised 4/2021, indicated “Instructs, supervises and evaluates home health aide care provided every two (2) weeks.”

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interview and record review the home health agency failed to ensure the established Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was provided to one of eight sampled patients, (Patient 6). This failure resulted in patient not receiving the care which had the potential to delay the healing process, could potentially cause complications that can affect the highest practicable well-being of the affected patient. A review of Patient 6’s clinical record, titled, “Patient Profile by Episode” indicated a Start of Care (SOC) date of 7/8/2023, with diagnoses including hypertension (high blood pressure) and diabetes mellitus type II (high blood sugar). A review of Patient 6’s clinical record, titled, “Home Health Certification and Plan of Care” dated from 7/8/2023 to 9/5/2023, indicated “Skilled nurse to perform observation/assessment of … all body systems emphasizing on … endocrine status… Skilled nurse to instruct/teach patient/PCG… signs and symptoms of hypo/hyperglycemia… proper care and maintenance of glucometer (machine to check blood sugar levels), diabetic skin and foot care; Skilled nurse to report to MD (physician) of patients BS (blood sugar) of less than 80 milligrams/decliter (mg/dl) or more than 300 mg/dl…”. A review of Patient 6’s Electronic Medical Record (EMR) on 8/8/2023, at 10:02 p.m., indicated there was no documented evidence the fasting blood sugar (FBS, a test that measures sugar (glucose) in the blood) from 7/12/2023 to 7/29/2023 were monitored for blood sugar level results. During a telephone interview on 8/9/2023, at 3 p.m., Patient 6’s Care Giver (PCG) stated Patient 6 was admitted on 7/8/2023 and has not received the glucometer the Home Health agency (HHA) was to provide. During an interview on 8/11/2023, at 11 a.m., the Administrator (ADM), stated that Patient 6’s medical doctor ordered the glucometer and the HHAs responsibility was to call the pharmacy to check on it. ADM stated further stated no one had followed up on it. A review of facility’s form titled “Registered Nurse – Job Title/Position” revised 4/2021, indicated “Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es). Regularly re-evaluates patient nursing needs. Initiates the plan of care and makes necessary revisions as patient status and needs change.” A review of facility’s policy and procedure titled, “Safe and Appropriate Use of Medical Equipment and Supplies” revised 4/2021, indicated “The Clinical Supervisor will establish a tracking mechanism to locate equipment used in the provision of care.” A review of facility’s policy and procedure titled, “Rights and Responsibilities” revised 4/2021, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: I. The organization shall ensure that the patient receives all services outlined in the plan of care.”

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 Home Health Agency (HHA) failed to ensure a Registered Nurse (RN) conducted the License Vocational Nurse (LVN) supervisory visit at least every 30 days, to monitor and evaluate the LVNs performance in the care and services provided to the four of eight sampled patients, (Patient 1, Patient 4, Patient 5, and Patient 8). This failure had the potential to result in a poor-quality patient care provided to the patients under the agency care. A review of Patient’s 1's “Patient Profile” indicated a start of care on 1/20/2023, with diagnoses that included chronic pain. During the home visit conducted on 8/10/2023, at 12:26 p.m. with the Director of Patient Care Services (DPCS), the DPCS was observed reviewing the medications Patient 1 was taking and comparing them to the medication list. The following were not listed in Patient 1’s medication list: Zyrtec (an allergy medication) 10 mg (mg-unit of measurement) tablet. Patient 1 stated she takes 1 pill a day since “months ago”. Patient 1 stated the medication was an over-the-counter medication (not prescribed). Multivitamin (a supplement) 1 tablet once a day. Patient 1 stated she started to take the medication 3 months ago. Tylenol (pain reliever) 500 mg, 1 tablet once a day. Patient 1 stated she takes the medicine for pain “many years ago”. Fish Oil (supplement), 1 capsule daily. Patient 1stated has been taking it for years. Vitamin B-12 (a supplement) 1 tablet daily. Patient 1 stated has been taking it for years. During an interview and concurrent record review on 8/10/2023, at 12:30 p.m. of Patient 1’s “Patient Medication Profile”, printed on 8/8/2023, with the DPCS, the record indicated “Metoprolol (a blood pressure medication) …50 mg tablet every 12 hours”. Patient 1 stated, 5 months ago, she started taking 1 tablet a day because the doctor instructed her to do so. The DPCS told Patient 1 to talk to the doctor so the doctor can clarify the medication she was taking. During an interview on 8/10/2023, at 12:45 p.m., the DPCS stated Patient 1’s medication profile list was not updated to reflect the current medications being taken. The nursing staffs visiting Patient 1 were expected to look at the medication label and compare it to the medication list to make sure it matches at every visit. When asked, the DPCS stated it was important to check the patient for changes, identify for complications or need for monitoring due to the medications the patient was taking. During an interview on 8/11/2023, at 1:30 p.m., the ADM stated the LVN taking care of Patient 1 had not been supervised by an RN. A record review of Patient 1’s “Nursing Progress Note” 6/27/2023, 7/4/2023, 7/20/2023, 7/25/2023, and 8/1/2023, indicated the patient was provided SN services by LVN. A review of Patient’s 4's “Patient Profile” indicated a start of care date of 9/7/22, with diagnoses including Type 2 diabetes (DM, high levels of sugar in the blood, a chronic condition). During a record review with the Administrator (ADM) of Patient 4’s “Plan of Care” for the certification period 7/4/2023 to 9/1/2023, on 8/11/2023, at 1:10 p.m., the record indicated a skilled nurse was to visit Patient 4 once a week for 9 weeks, instruct and teach about signs and symptoms of low (hypoglycemia), high sugar (hyperglycemia) in the blood, and monitor the level of sugar in the blood. When asked, the ADM stated it was important for the nurse visiting Patient 4 to take a reading on the blood sugar level to make sure it is in the desired range, as ordered by the doctor. During a concurrent interview and record review on 8/11/2023, at 1:25 p.m., Patient 4’s “Nursing Progress Notes”, for the dates, 7/7/2023,7/14/2023, 7/21/2023, and 7/28/2023, were reviewed with the ADM and the records indicated the visits were done by a Licensed Vocational Nurse (LVN). The ADM stated there were no blood sugar levels taken and there was no diabetes management education provided to the patient. The LVN failed to provide the services in accordance with the POC. During an interview on 8/11/23, at 1:30 p.m., the ADM stated the Registered Nurse (RN) have not been supervising the LVN and stated it was important for the RN to supervise the LVN to ensure quality care was being provided to the patients. A review of Patient 5’s “Patient Profile by Episode” indicated a Start of Care (SOC) date of 12/8/2022, with diagnoses including DM and hypertension (high blood pressure). A review of Patient 5’s Electronic Medical Record (EMR) on 8/8/2023 at 8:42 p.m., indicated there were two License Nurse Supervisory Notes dated 4/7/2023 and 7/5/2023 that were not completed and left blank. During a concurrent interview and record review on 8/10/2023, at 3:10 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that there were no LVN supervisory visits conducted for Patient 5. The DPCS also stated that the LVN supervisory visits should be done every 30 days to “check how they present and demonstrate. If the LVN is not supervised, we don’t know if the nurse is doing the right thing. Something could happen to the patient; some harm could happen to the patient”. A review of Patient 8’s medical record form titled “Patient Profile by Episode” indicated a Start of Care (SOC) date of 3/29/2023, diagnoses including DM and hypertension. A review of Patient 8’s Electronic Medical Record (EMR) on 8/8/2023, at 9:16 p.m., indicated there was a License Nurse Supervisory Notes dated 6/28/2023, however, the note was left blank or not completed. A review of Patient 8’s Electronic Medical Record (EMR) on 8/8/2023 at 9:12 p.m., indicated “Nursing Progress Note – Supervisory Visit” were left blank on 5/30/2023, 6/6/2023, 6/13/2023, 6/22/2023, 6/27/2023, 7/4/2023, 7/11/2023, 7/18/2023, 7/25/2023, 8/1/2023, and 8/8/2023. During a concurrent interview and record review on 8/11/2023, at 12 p.m. with the Administrator (ADM), the ADM acknowledged there were no LVN supervisory visits documented for Patient 8. ADM stated the RN conducts the LVN supervisory visit “to make sure they are doing their job and to prevent any medication errors, to make sure patient is receiving the care that has been ordered”. A review of facility’s policy and procedure titled “Supervision” revised 4/2021, indicated “A registered nurse will be available … Licensed Vocational nurses will be supervised every 30 days.” A review of facility’s policy and procedure titled, “Rights and Responsibilities” revised 4/2021, indicated “Supervisory visits with clinical disciplines will be conducted to ensure these rights are honored and protected according to organizational policy.”

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) failed to ensure the Condition of Participation for Clinical Records were met as follows: 1.The HHA failed to ensure the plan of care (documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers), comprehensive assessment (an assessment conducted by a Registered Nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records), and physician’s orders were available in the clinical records for the eight of eight sampled patients, (Patients 1, 2, 5, 6 and 8). This failure had the potential that staff involved in providing direct patient care will not provide the appropriate care and services necessary to maintain the highest practicable, mental, medical, and physical well-being of all the patients under the agency’s care. (Refer to G1012) 2.The HHA failed to ensure the clinical records contained an accurate medication list that reflected the current medications for two of eight sampled patients, (Patient 5 and Patient 6). This failure had the potential to result in medication errors and adverse drug reactions. (Refer to G1014) 3. The HHA failed to ensure, the discharge summary for one of eight sampled patients, (Patient 7), was sent to the patient’s primary physician within 5 days of discharge. This deficient practice had the potential to result in communication failure as regards the discharge status of the affected patient, (Patient 7). (Refer to G1022) 4. The HHA failed to ensure the clinical records for one of eight sampled patients, (Patient 2), were appropriately authenticated, dated, and timed. This failure resulted in an incomplete medical record and had records with unknown author, not dated and timed. (Refer to G1024) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Clinical Records to ensure the provision of a quality health care is provided to patients receiving the home health benefits.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview, and record review the Home Health Agency (HHA) failed to ensure the plan of care (documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers), comprehensive assessment (an assessment conducted by a Registered Nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records), and physician’s orders were available in the clinical records for the eight of eight sampled patients, (Patients 1, 2, 5, 6 and 8). This failure had the potential that staff involved in providing direct patient care will not provide the appropriate care and services necessary to maintain the highest practicable, mental, medical, and physical well-being of all the patients under the agency’s care. On 8/8/2023, at 1:33 p.m., the plans of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for Patients 1, 2, 5, 6, and 8 were requested from the Administrator (ADM) to be reviewed. On 8/8/2023, at 1:55 p.m., the POC for Patients 1, 2, 5, 6, and 8 were requested from the Director of Patient Care Services (DPCS) to be reviewed. On 8/8/2023, at 3 p.m., the requested POC for Patients 1, 2, 5, 6, and 8 were still not provided. During an interview on 8/8/2023, at 3:25 p.m., with Quality Assurance (QA), the QA stated that Patients 1, 2, 5, 6, and 8 did not have the current Home Health Certification and Plan of Care (POC) and was unable to provide all the documents requested. QA stated that the POC was supposed to be completed within five days of certification or recertification and it is the plan of treatments based on the patient needs. QA also stated that the visiting nurse is verbally made aware what the patient needs for treatment were and that their needs are based on the narrative notes completed by the RN (registered nurse). QA further stated that this was not a best practice, and that the visiting nurse should have communicated with the HHA via their cell phone if they don’t have a current POC on hand. During an interview on 8/10/2023, at 10:36 a.m., with the ADM, the ADM stated that whatever is documented on the comprehensive assessment (an assessment conducted by a Registered Nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records) automatically populates to the POC and the whole system for that patient. A review of Patient’s 1's “Patient Profile” indicated a start of care on 1/20/2023, with diagnoses including chronic pain. During a concurrent interview and record review on 8/11/2023, at 1:26 p.m., Patient 1’s clinical record titled, “Recertification (Follow up) assessment, dated 8/8/2023 was reviewed with the Administrator (ADM). The clinical record indicated the assessment was for certification period 7/19/2023 to 9/16/2023. The ADM stated Patient 1’s updated assessment was completed on 8/8/2023 and was considered late. When asked, the ADM stated the comprehensive assessment was supposed to be completed within 48 hours to one week from the beginning of the recertification date. The ADM also stated the comprehensive assessment was important for the proper care planning and care of the patients since the assessment drives the care plan. The risk of not completing the comprehensive assessment in a timely manner is delay of care. The nurse will not know how to care for the patient. If there is no assessment, there is no care plan. A review of Patient 1’s record titled “Home Health Certification and Plan of Care”, for certification period 7/19/2023 to 9/16/2023, indicated the care plan was done on 8/8/2023 at 10:48 p.m. The HHA failed to ensure Patient 1’s clinical record included a comprehensive assessment and plan of care. A review of Patient’s 2's “Patient Profile” indicated a start of care on 7/15/2023, with diagnoses including hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 8/8/2023 at 3:23 p.m., Patient 2’s medical record was reviewed with the QA. There was no plan of care (POC) documented in Patient 2’s record. The QA stated the POC was supposed to be done within 5 days of the start of care, but staff were swamped and could not complete the POC. The QA stated the purpose of the POC was the plan of treatment, tells staff what needs to be assessed, education needed to be provided, reportable conditions, and who needs to be contacted in case of an emergency. During an observation of the home visit on 8/9/2023, at 10:15 a.m., the DPCS) was observed providing care to Patient 2. During an interview on 8/9/2023, at 10:30 a.m., the patient caregiver stated to the DPCS, Patient 2 was a diabetic. During an interview on 8/10/2023, at 11:22 a.m., the DPCS stated the comprehensive assessment and plan of care were done on 8/8/23. The HHA failed to ensure Patient 2’s clinical record included a comprehensive assessment and plan of care. During an interview on 8/10/2023 at 10:38 a.m., the QA stated no one had spoken to Patient 2’s Primary Medical Doctor 4 (PMD 4). During a concurrent interview and record review on 8/10/2023, at 12:59 p.m., Patient 2’s clinical record titled “Physician Orders” dated 7/15/2023 at 10:19 a.m.”, was reviewed with the DPCS. The clinical record indicated Patient 2’s PMD 4 had ordered an admission to the HHA and a skilled nurse comprehensive assessment. When asked, the DPCS stated the date of 7/15/2023 reflected the order obtained from the General Acute Care Hospital’s referral, and not from PMD 4. The DPCS did not speak to PMD 4 on 7/15/2023. When asked why she signed the document, if she did not get the order from PMD 4, she stated, “That’s a good question. I don’t know. I electronically signed it. Signature means my RN (Registered Nurse) license. That I am held responsible. That I received the phone call from the doctor. I didn’t get the order. No, this document is not accurate.” During a concurrent interview and record review on 8/10/2023, at 1:05 p.m., Patient 2’s record titled “Physician Orders” dated 7/15/2023 at 10:40 a.m.”, was reviewed with the DPCS. The record indicated an order for admission to the HHA for certification period 3/24/22 to 5/22/22 from Patient 2’s PMD 4. Further review of the record indicated the DPCS read back and verified the order with PMD 4. The DPCS stated the certification dates were wrong, she did not speak to the doctor on 7/15/2023, and she should have double checked the document to make sure it was correct. During a concurrent interview and record review on 8/10/2023, at 1:11 p.m., Patient 2’s clinical record titled “Physician Orders” dated 7/18/2023 at 8:47 a.m.”, was reviewed with the DPCS. The record indicated the DPCS had read back and verified the orders with PMD 4. The DPCS stated she did not speak to PMD 4 on 7/18/2023 and had signed the document even though she did not enter the order herself because she trusted the person who documented the order. During a concurrent interview and record review on 8/10/2023, at 1:11 p.m., Patient 2’s record titled “Physician Orders” dated 7/22/2023, 8/8/2023, and 8/9/2023”, was reviewed with the DPCS. The documents indicated the DPCS had obtained orders from PMD 4, however, the DPCS stated she signed these orders, even though she did not speak to the doctor. A review of Patient 5’s medical record form titled “Patient Profile by Episode” indicated a Start of Care (SOC) date of 12/8/2022, diagnoses including DM and yypertension. A review of Patient 5’s medical record titled “Recertification (follow-up) assessment” dated from 6/6/2023 to 8/4/2023, was provided on 8/8/2023. A review of Patient 6’s medical record form titled “Patient Profile by Episode”, indicated Patient 6 had a Start of Care (SOC) date of 7/8/2023, diagnoses including hypertension and DM. A review of Patient 6’s medical record titled “Recertification (follow-up) assessment” dated from 7/8/2023 to 9/5/2023, was provided on 8/9/2023. A review of Patient 8’s medical record form titled “Patient Profile by Episode”, indicated Patient 8 had a Start of Care (SOC) date of 3/29/2023, diagnoses including DM and hypertension. A review of Patient 8’s medical record titled “Recertification (follow-up) assessment” dated from 7/27/2023 to 9/24/2023, was provided on 8/9/2023. A review of facility’s policy and procedure titled, “Initial and Comprehensive Assessment” revised 4/2021, indicated “A comprehensive patient assessment will be completed within five (5) calendar days of the patients start of care… and at the following defined intervals thereafter: for recertification within the last five (5) das of every 60-day episode…” A review of facility’s policy and procedure titled “Reassessment/Recertification” revised 4/2021, indicated “The comprehensive assessment must be updated and revised every second calendar month, beginning with the start of care. The total plan of care must be renewed at least every 60 days…” A review of facility’s policy and procedure titled, “Care Planning Process” revised 4/2021, indicated “The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient.” A review of facility’s form titled “Registered Nurse – Job Title/Position” revised 4/2021, indicated “Initiates the plan of care… develops a care plan…”

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to ensure the clinical records contained an accurate medication list that reflected the current medications for two of eight sampled patients, (Patient 5 and Patient 6). This failure had the potential to result in medication errors and adverse drug reactions. A review of Patient 5’s medical record form titled, “Patient Profile by Episode”, indicated a Start of Care (SOC) date of 12/8/2022, diagnoses including diabetes mellitus type II (DM, high blood sugar) and hypertension (high blood pressure). A review of Patient 5’s medical record titled, “Patient Medication Profile”, indicated docusate (a stool softener) 100 milligrams (mg), multivitamin (supplement), vitamin D3 (supplement), were in the list. A review of Patient 5’s Assisted Living Facility’s (ALF) medical record titled, “Central ordered Medication and Destruction Record” did not indicate documented lists of Docusate, Multivitamin or Vitamin D3. During a joint home visit at Patient 5s ALF on 8/9/2023, at 11:20 a.m., with License Vocational Nurse 1 (LVN1), LVN1 conducted the medication review using the home health agency’s (HHA) medication list and Patient 5’s medication bottles and had discrepancies found. LVN1 was unable to locate the docusate, multivitamin, and vitamin D3 medication bottles. ALF Medication Nurse (MN) stated that they have their own medication list for Patient 5, and do not have or use the HHA’s list. The ALF Medication Nurse (MN) stated that Patient 5 has never been given docusate, multivitamin, or vitamin D3. During a concurrent interview and record review on 8/10/2023, at 4:09 p.m., with the Director of Patient Care Services (DPCS) of Patient 5’s Electronic Medical Record (EMR), the DPCS stated that medication reconciliation should be done at every visit and if there is a change in the patients’ medication, to prevent overdose of medication. A review of Patient 6’s medical record form titled “Patient Profile by Episode” indicated Patient 6 had a Start of Care (SOC) date of 7/8/2023, diagnoses including hypertension and DM. A review of Patient 6’s medical record titled “Patient Medication Profile” dated 7/8/2023, indicated Patient 6 was prescribed metformin (DM medicine) 500 mg 1 tab PO (by mouth) BID (twice a day), amlodipine (medicine for high blood pressure) 5/160 mg 1 tab PO QHS (at bedtime) and Kava Kava 200mg 1 tab PO PRN (as needed) anxiety. During a telephone interview on 8/9/2023 at 3 p.m., with Patient 6’s Care Giver (PCG), stated that Patient 6 was currently taking ativan/lorazepam 0.5 mg 1 tablet po TID (three times per day) as needed for anxiety, catapres (medicine for high blood pressure) 0.1 mg 1 tablet TID as needed for SBP> (systolic blood pressure – over) 160, metformin 500mg 1 tab PO BID, amlodipine (medicine for high blood pressure) 5/160 mg 1 tab PO every morning. When asked, PCG stated, “the ativan and catapres were added by the doctor last month and I just received the medications two weeks ago.” During an interview on 8/10/2023, at 10:49 a.m., with the Administrator (ADM), the ADM stated that the registered nurse (RN) and the quality assurance (QA) is responsible for reviewing and revising the patient’s medication list. ADM stated that the medication list is reviewed and revised “whenever there are changes on recertification, and at every visit”. During an interview on 8/10/2023 at 4:09 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the medication reconciliation is done at every visit and when the patient has a doctor’s visit. DPCS stated that the patients’ medical record needs to be updated to prevent errors. During an interview on 8/11/2023 at 11 a.m. the ADM stated “the reconciliation should be done at every visit. They have the medication sheets and the physical medication you compare one by one, the five rights. It important to have a current updated medication list to avoid any medication errors.” A review of facility’s policy and procedure titled, “Medication Profile” revised 4/2021, indicated “Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.” A review of facility’s policy and procedure titled, “Medication Monitoring” revised 4/2021, indicated “Ongoing patient medication monitoring will use a collaborative approach among the clinicians…”

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 home health agency failed to ensure the discharge summary for one of eight sampled patients, (Patient 7), was sent to the patient’s primary physician within 5 days of discharge. This deficient practice had the potential to result in communication failure as regards the discharge status of the affected patient. A review of Patient 7’s medical record form titled, “Patient Profile by Episode” indicated Patient 7 had a Start of Care (SOC) date of 2/15/2023 and an End of Care (EOC) date of 2/28/23, diagnoses including diabetes mellitus type II (DM, high blood sugar), hypertension (high blood pressure), and pressure ulcer stage II on sacral region (shallow open skin ulcer). A review of Patient 7’s Electronic Medical Record (EMR) on 8/8/2023 at 9:42 p.m., indicated a death discharge (DC) note was documented for Patient 7 on 2/28/2023. Under the section “Copy of Summary” sent to physician, was marked as sent, however, the notes did not indicate the physician’s name and the date it was sent. During a concurrent interview and record review on 8/11/2023 at 11:45 a.m. with the Administrator (ADM), the ADM stated, “the discharge summary should have been sent to the doctor involved in the care, so he knows the patient had been discharged and he can also discharge Patient 7 from his system and sign the death certificate. This summary, they did not put in the date or the doctor it was sent to, it's incomplete.” A review of facility’s policy and procedure titled, “Discharge Summary” revised 4/2021, indicated “a copy of the discharge summary will be provided to the patient’s primary care practitioner… within five (5) business days of the patients discharge. A discharge summary will be completed… a copy will be mailed to the primary physician.”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the clinical records for one of eight sampled patients, (Patient 2), were appropriately authenticated, dated, and timed. This failure resulted in an incomplete medical record and had records with unknown author, not dated and timed. During an interview on 8/10/2023, at 10:38 a.m., the Quality Assurance staff (QA) stated no one had spoken to Patient 2’s Primary Medical Doctor 4 (PMD 4). During a concurrent interview and record review on 8/10/2023, at 12:59 p.m., Patient 2’s record titled “Physician Orders” dated 7/15/23 at 10:19 a.m.”, was reviewed with the Director of Patient Care Services (DPCS). The record indicated Patient 2’s PMD 4 had ordered an admission to the home health agency (HHA) and a skilled nurse comprehensive assessment (an assessment conducted by a Registered Nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records). The DPCS did not speak to PMD 4 on 7/15/2023, at 10:19 a.m. When asked why the DPCS signed the document if she did not get the order from PMD 4, she stated, “That’s a good question. I don’t know. I electronically signed it. Signature means my RN (Registered Nurse) license. That I am held responsible. That I received the phone call from the doctor. I didn’t get the order. No, this document is not accurate.” During a concurrent interview and record review on 8/10/2023, at 1:05 p.m., Patient 2’s record titled “Physician Orders” dated 7/15/2023 was reviewed with the DPCS. The record indicated the DPCS read back and verified the order with PMD 4. During further review, the clinical record indicated the DPCS completed the order on 8/10/23, however, the DPCS stated she did not speak to the doctor on 7/15/2023. The DPCS stated the order should have been signed (authenticated) on the date the order was received because that was when the order must be implemented. If the order is documented later, it meant the order wasn’t written until a later date. The DPCS stated the person entering the order should have signed the document, and stated she signed the order even though she didn’t receive it. During a concurrent interview and record review on 8/10/23, at 1:11 p.m., Patient 2’s record titled “Physician Orders” dated 7/18/23 at 8:47 a.m.”, was reviewed with the DPCS. The record indicated the DPCS read back and verified the order with PMD 4. Further review of the record indicated the order was authenticated on 8/10/2023. The DPCS stated she did not speak to PMD 4 on 7/18/2023. The DPCS stated she signed the document even though she did not enter the order herself. The reason she signed the document was because she trusted the person who documented the order. During a concurrent interview and record review on 8/10/2023, at 1:11 p.m., Patient 2’s record titled “Physician Orders” dated 7/22/2023, 8/8/2023, and 8/9/2023”, was reviewed with the DPCS. The documents indicated the DPCS had obtained orders from PMD 4. The DPCS stated she signed these orders, even though she did not speak to the doctor. The DPCS stated the person who input the orders into Patient 2’s record needed to authenticate the records. During an interview on 8/10/23, at 1:21 p.m., the Quality Assurance staff (QA) stated she had documented the orders in Patient 2’s records, as instructed by the nurses. QA stated after the order is entered the order is given to the nurse for authentication. Once the order is authenticated, the order is faxed to the doctor. The QA staff stated she was not a licensed nurse. A review of facility’s policy and procedure titled “Entries into the clinical Record”, revised 4/2021, indicated, “the clinical note will include signature of clinician and his/her credentials. A clinical record… will include at a minimum: Patient consent, authorization, and election forms… Pertinent medical history. The clinical note will include signature of clinician and his or her credentials.”