Every finding on record at Nevada Gem Home Health

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an agency that provides care and therapy services to patients) failed to ensure an Emergency Preparedness Plan (a set of steps and resources to help keep people safe during unexpected events like fires or storms and outlines what to do and how to communicate before, during, and after an emergency) policy was complete with procedures for transferring patients and keeping communication with staff during an emergency. This failure had the potential to result in the patients being at risk for not receiving continuity of care. Findings: During an interview on 1/20/2026 at 12:59 PM, with the Administrator (ADM), the ADM stated the purpose of an emergency preparedness plan was that in case of an earthquake or a fire, the agency could ensure that patients were taken care of and the patients could continue receiving care. During a concurrent interview and record review on 1/20/2026 at 12:59 PM, with the ADM, the facility’s policy and procedure (P&P) titled, “Emergency Preparedness Plan”, revised 4/2025, was reviewed. The P&P did not indicate the following: The facility had an agreement with surrounding facilities for patients to be transferred to. A time frame for transferring patients in case of an emergency.What actions would the HHA take if contact with the staff was lost.The timeframe in which a staff member should report to the agency.The ADM stated there was no agreement between the agency and surrounding facilities such as a hospital or a nursing facility but there should be an agreement in place. The ADM stated it would be good to have an agreement with different facilities, and it would give the facilities a chance to make a plan and facilitate care to the patients. The ADM stated the policy did not outline the steps that are needed for the agency to be able to have communication with their staff. The ADM stated communication is key and that the agency should have alternatives to locating their staff listed, such as physically looking for their staff. The ADM stated the policy does not include a time frame for when the staff should be contacting the agency in case of an emergency and stated that it would be good to include a time frame in the policy and that it was important to ensure that the agency checks in with their staff.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Complaint: 114383 Census: 15 Unduplicated admissions: 37 Sample Size: 7 Home Visits: 3 Closed Record review: 2 The following Conditions of Participation (COP) are not met: 484.55 Condition of Participation: Comprehensive Assessment of Patients 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care 484.65 Condition of Participation: Quality assessment and performance improvement (QAPI) 484.110 Condition of Participation: Clinical Records

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to patients' personal residence) failed to provide and ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) had Federal and State funded entity information. This failure had the potential to prevent patients be familiar with the services that are available to them. During a record review of Patient 1’ Patient Information sheet, indicated a start of care of 3/21/2025, with primary diagnoses including hypertensive heart disease (high blood pressure) and kidney failure (kidneys unable to work). During a record review of Patient 2’s Patient Information sheet, indicated a start of care of 8/11/2025, with a primary diagnosis of bilateral (both sides) osteoarthritis (arthritis-stiffening of the joints) of the hip. During a record review of Patient 3’s Patient Information sheet, indicated a start of care of 7/6/2025, with a primary diagnosis of heart failure (heart unable to pump blood effectively to the body). During a record review of Patient 4’s medical record form titled “Patient Information” undated, indicated a start of care date of 8/16/2025 with a primary diagnosis of essential hypertension (high blood pressure). During a record review of Patient 5’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/15/2025 with a primary diagnosis of age-related osteoporosis (brittle and fragile bones) without current pathological fracture. During a record review of Patient 6’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/20/2024 with a primary diagnosis of other intervertebral disc degeneration lumbar region with discog back & lower extremity pain. During a record review of Patient 7’s medical record form titled “Patient Information” undated, indicated a start of care date of 5/24/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar) without complications. During a concurrent interview and record review on 1/13/2026 at 5 p.m., with the Administrator (ADM), the ADM provided a patients admission folder and stated it was complete and had all the required documents patients and their families needed. During a concurrent interview and record review on 1/20/2026 at 2:28 p.m., with Registered Nurse 2 (RN2) of agency’s patient admission folder, the RN2 stated that the folder did not have resource references. RN2 stated that the patients and their families required resource information to be able to know who to contact if the needs arise. During a record review of the HHA’s patient admission folder, there was no information on Federally funded and state-funded entities that serve the area where the patient resides. During a record review of the HHA’s document titled Patient Rights and responsibilities, dated 2025, the document indicated that the HHA “shall protect and promote each patient’s rights and shall inform each patient (or representative) of these rights in advance of furnishing care or during the initial evaluation visit.”

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: Based on observation, interview, and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to review and document all the medications and treatments the patient was currently using for two of seven sampled patients (Patient 4 and Patient 5). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). 2. The HHA failed to ensure a Registered Nurse updated the comprehensive assessment for the recertification period for two of seven sampled patients (Patient 3 and Patient 5). This deficient practice had the potential to result in decline in health status by not assessing the patient’s current needs. (Refer to 546). 3. The HHA failed to update two of seven sample patient (Patient 2 and Patient 7) comprehensive assessment at discharge. This failure had the potential to result in missed care which could result in decline in health status by not assessing if the patient met the care plan goals. (Refer to G550). 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.

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 – an organization that delivers skilled nursing and other therapeutic services to patients personal residence) failed to review and document all the medications and treatments the patient was currently using for two of seven sampled patients (Patient 4 and Patient 5). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. 1. During a record review of Patient 4’s medical record form titled “Patient Information” undated, indicated a start of care date of 8/16/2025 with a primary diagnosis of essential hypertension (high blood pressure). During a record review of Patient 4’s medical record form titled “Home Health Certification and Plan of Care” dated from 12/14/2025 to 2/11/2026, indicated these were some of the medications Patient 4 was prescribed: Morphine Sulfate ER (extended-release pain medication) Oral 15 mg (milligrams – measure of unit) 1 Tab(s) Every 6 hours prn (as needed). Remeron (anti-depressive medication) Oral 30 mg 1 Tab(s) Daily Colace (stool softener) Oral 100 mg 1 Cap(s) PRN constipation Baclofen (muscle relaxer) Oral 10 mg 1 Tab(s) 4 times per day Mirtazapine (anti-depressive medication) Oral 30 mg 1 Tab(s) Daily at bedtime During a record review of Patient 4’s medical record form titled “Medication Profile” dated from 12/14/2025 to 2/11/2026, indicated under section “current medications” these were some of the medications Patient 4 was taking: Colace Oral 100 mg1 Cap(s) twice a day PRN constipation Baclofen Oral 10 mg 1 Tab(s) 3 times per day During a record review of Patient 4’s medical record form titled “Patient Medication Record” dated from 12/14/2025 to 2/11/2026 and printed on 1/14/2026 at 8:25 a.m., indicated these were some of the medications Patient 4 was taking: Colace Oral 100 mg 1 Cap(s) twice a day PRN constipation Baclofen Oral 10 mg 1 Tab(s) 3 times per day Mirtazapine Oral 30 mg 1 Tab(s) Daily at bedtime During a record review of Patient 4’s medical record form titled “Patient Medication Record” dated from 12/14/2025 to 2/11/2026 and printed on 1/14/2026 at 8:26 a.m., indicated these were some of the medications Patient 4 was taking: Morphine Sulfate ER Oral 15 mg 1 Tab(s) Every 6 hours prn Baclofen Oral 10 mg 1 Tab(s) 4 times per day Colace Oral 100 mg 1 Cap(s) PRN constipation Remeron Oral 30 mg 1 Tab(s) Daily Mirtazapine Oral 30 mg 1 Tab(s) Daily at bedtime During a concurrent observation, interview, and record review on 1/14/2026 at 11:13 a.m., with Patient 4 at her residence of Licensed Vocational Nurse 1 (LVN1), LVN1 did not reconcile Patient 4’s home medication with the HHA’s documented medication list. Patient 4 agreed to have her medications reconcile. The following discrepancies were noted: Col-Rite 100mg take 1 capsule twice a day; Vitamin B1 100mg, Patient 4 stated she (Patient 4) takes one pill a day; Biotin (supplement) 10,000 mcg (micrograms), Patient 4 stated she takes one pill a day; Baclofen 10 mg three times per day. During an interview on 1/14/2026 at 11:45 a.m., with LVN1, stated she was not planning on reconciling Patient 4’s medications. LVN1 stated she did not conduct the medication reconciliation because she did not want to interrupt this writer while conducting the reconciliation. LVN1 stated that other surveyors conducted the medication reconciliation on their own. LVN1 stated patients' medications need to be reconcile at every visit for patient safety. During a concurrent interview and record review on 1/15/2026 at1:50 p.m. with Registered Nurse 2 (RN2) of Patient 4’s medical record, RN2 stated that visiting nurses are to check patients' medications during every visit to ensure the patient is taking the proper medication. RN2 stated when patients medications are not reconciled, the HHA will not be aware that the medications are being taken properly to prevent further issues. 2. During a record review of Patient 5’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/15/2025 with a primary diagnosis of age-related osteoporosis (brittle and fragile bones) without current pathological fracture. During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 11/15/2025 to 1/13/2026, indicated Patient 5 was prescribed the following medications: Tylenol Extra Strength Oral 500 mg 1 Tab(s) daily 1-2 times a day as needed Nexletol (cholesterol medication) Oral 180 mg 1 Tab(s) oral daily Synthroid (thyroid hormone) Oral 75 mcg 1 Tab(s) oral daily Trelegy Ellipta (asthma medication) Inhalation 100-62.5-25 MCG/ACT 1 inhaled dose daily During a record review of Patient 5’s medical record form titled “Patient Medication Record” dated from 11/15/2025 to 1/13/2026 and printed on 1/14/2026 at 9:04 a.m., indicated Patient 5’s current medications were: Albuterol Sulfate HFA Inhalation 108 (90 Base) MCG/ACT 1puff every 4-hrs PRN Nexletol Trelegy Ellipta Inhalation Synthroid During an observation on 1/14/2026 at 12 p.m., of Licensed Vocational Nurse 1 (LVN1) at Patient 5’s residence, LVN1 did not reconcile Patient 5’s home medication with the HHA’s documented medication list. During an interview on 1/14/2026 at 12:30 p.m. with LVN1, LVN1 stated patients' medications need to be reconcile at every visit for patient safety. LVN1 stated that if patients' medications are not reconciled there was a possibility of overdosing or not taking the medication as indicated. LVN1 stated that she (LVN1) did not know if Patient 4 or Patient 5 had expired medications because she (LVN1) did not reconcile their medications. During a concurrent interview and record review on 1/20/2025 at 11:55 a.m. with Registered Nurse 2 (RN2) of Patient 5’s medical record, RN2 stated that patients' medications should be reconciled at every nursing visit to prevent errors.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure a Registered Nurse updated the comprehensive assessment for the recertification for two of seven sampled patients (Patient 3 and Patient 5). This deficient practice had the potential to result in decline in health status by not assessing the patient’s needs. 1. During a record review of Patient 3’s Patient Information sheet, indicated a start of care of 7/6/2025, with a primary diagnosis of heart failure (heart unable to pump blood effectively to the body). During a record review of Patient 3’s medical records, on 1/14/2026, there was no recertification assessment for the certification period 1/2/2026 to 3/2/2026. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 1/15/2026 at 4:30 p.m., RN 2 reviewed Patient 3’s medical records and stated record titled, OASIS recertification assessment, dated 12/30/2025 was in Patient 3’s records. RN 2 stated this was the assessment used to recertify Patient 3 for period 1/2/2026 to 3/2/2026. During a concurrent interview and record review with the administrator (ADM) on 1/15/2026, at 4:31 p.m., the ADM reviewed the task details report (a report that tracks when documentation is entered and edited) for Patient 3’s record titled, OASIS recertification assessment, dated 12/30/2025. The ADM stated the OASIS recertification assessment dated 12/30/2025 was entered into Patient 3’s medical records on 1/14/2026. During an interview on 1/15/2026, at 4:32 p.m., with RN 2, RN 2 stated the recertification assessment should have been done 5 days prior to the new certification period. In this case, on 12/28/2025. The reason it should have been done was to give time for the plan of care to be done for the next certification period, so the nurse knows what needs to be done for the patient. RN 2 stated the assessment identifies what the new problems are, what the medications are, and any issues that warrant interventions for the plan of care. 2. During a record review of Patient 5’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/15/2025 with a primary diagnosis of age-related osteoporosis (brittle and fragile bones) without current pathological fracture. During a record review on 1/20/2026 at 10:30 a.m. of Patient 5’s medical record, the medical record indicated Patient 5’s certification period from 11/15/2025 to 1/13/2026, scheduled recertification assessment dated for 1/10/2026, was “not started”. During a record review on 1/20/2026 at 10:30 a.m. of Patient 5’s medical record, the medical record did not indicate Patient 5 had a recertification assessment completed for certification period from 1/14/2026 to 3/14/2026. During a joint home visit on 1/14/2026 at 12 p.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 5’s residence, LVN1 assessed Patient 5 using Patient 5’s plan of care dated 11/15/2025 to 1/13/2026. During a concurrent interview and record review on 1/20/2026 at 11:55 a.m. with Registered Nurse 2 (RN2) of Patient 5’s medical record, RN2 stated there was no documented recertification assessment for Patient 5’s certification period 1/14/2026 to 3/14/2026. RN2 stated that a rectification assessment evaluates the needs to continue HH services, to provide proper quality of care, and treatment. RN2 stated that she (RN2) does not know if Patient 5 qualified for HH services. During a record review of the HHA’s document titled, Recertification Policy, dated 2025, indicated, “A comprehensive recertification assessment shall be completed no earlier than Day 56 and no later than Day 60 of the current certification period.”

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure two of seven sample patients (Patient 2 and Patient 7) comprehensive assessments are updated at discharge. This failure had the potential to result in missed care which could result in decline in health status by not assessing if the patient met the care plan goals. 1. During a record review of Patient 2’s Patient Information sheet, indicated a start of care of 8/11/2025, with a primary diagnosis of bilateral (both sides) osteoarthritis (arthritis-stiffening of the joints) of the hip. During a record review of Patient 2’s Physician Order, dated 12/5/2026, the record indicated Patient 2 was to be discharged from home health services. During a concurrent interview and record review on 1/20/2026, at 1:54 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 2’s medical records. The records indicated an OASIS-E1 transfer was documented on 12/5/2025. RN 2 stated Patient 2’s order was to discharge; therefore, a discharge assessment was required. RN 2 stated she did not know why a discharge assessment was not done. 2. During a record review of Patient 7’s medical record form titled “Patient Information” undated, indicated a start of care date of 5/24/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar) without complications. During a record review of Patient 7’s medical record form titled “OASIS-E1 Discharge (Non-Billable)” dated 12/18/2025, indicated the assessment was completed on 12/18/2025 due to Patient 7 being discharge from the HHA on 12/18/2025 per patient/family request. The vital sign section was left blank. The assessment did not indicate the authors name or signature. During a record review of Patient 7’s medical record form titled “Task Details - OASIS-E1 Discharge (non-Billable)” undated, indicated the OASIS-E1 Discharge (non-Billable) form dated 12/18/2025 was created on 1/13/2026 and completed on 1/14/2026 by the Case Manager 1 (CM1). During a concurrent interview and record review on 1/15/2026 at 4:23 p.m. with the Administrator (ADM) of Patient 7’s medical record, the ADM stated that Patient 7’s discharge summary/assessment dated 12/18/2025 was created on 1/13/2026. The ADM stated he noticed Patient 7 was listed as an active patient on 1/13/2026 when he (ADM) was requested to print a current patient census for the HHA. During a concurrent interview and record review on 1/20/2026 at 12:27 p.m. with Registered Nurse 2 (RN2) of Patient 7’s medical record, RN2 stated that patients discharge assessment must be completed to ensure the ordered care was completed, to provide instructions, and to ensure the patient no longer needed home health services. RN2 stated Patient 7’s discharge assessment should have been completed when he (Patient 7) was discharge on 12/18/2025. RN2 stated that Patient 7’s discharge assessment was completed on 1/13/2026. During an interview on 1/20/2026 at 2:11 p.m. with the Case Manager 1 (CM1), CM1 stated she was responsible for transcribing physician orders and documents into patients' medical records. CM1 stated that she writes notes to remind herself what needed to be inputted in the patients’ medical records. CM1 stated that she was busy and that it may take up to a month to transcribe physician orders or notes into the patients’ medical record and that it was not an acceptable practice. CM1 stated that an assumption was made that a document was entered and created on the date that was documented, and in actuality it was entered on a different date. CM1 was requested to provide the physical documents that were used to enter the patient's information in their medical record. CM1 stated did not have those documents, but was able to provide a sheet of paper with writing on it, without a date. During a record review of the HHA’s document titled, Discharge Policy, dated 2025, indicated, “For planned discharges, CNHHA shall...Complete a discharge assessment and summary.”

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 interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure the Condition of Participation regarding Care Planning, Coordination, and Quality of Care was met as follows: 1. The HHA failed to ensure the Plan of Care (POC) was created and followed for three of seven sampled patients (Patient 1, Patient 3, and Patient 5). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC (Refer to G572). 2. The HHA failed to include information required in the plan of care for one of seven sampled patients (Patient 1). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. (Refer to G574). 3. The HHA failed to ensure licensed personnel received and transcribe physician orders for one of seven sample patients (Patient 3). This failure had the potential to result in missed or inappropriate care orders that can cause injury to the patient. (Refer to G584). 4. The HHA failed to ensure the physician was informed/made aware of one of seven sample patients (Patient 5) change of condition. This failure had the potential to result in the patient being hospitalized due to low blood pressure and/or HHA staff is not aware of the patient's status. (Refer to G590). 5. The HHA failed to ensure the physician was made aware three of seven sample patients (Patient 2, Patient 6 and Patient 7) were discharged. This failure had the potential to result in patients do not receive services that can potentially be detrimental to their health. (Refer to G598). 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 – an organization that delivers skilled nursing and other therapeutic services to patients' personal residence) failed to ensure the Plan of Care (POC) was developed or followed for three of seven sampled patients (Patient 1, Patient 3, and Patient 5). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC. 1. During a record review of Patient 1’ Patient Information sheet, indicated a start of care of 3/21/2025, with primary diagnoses including hypertensive heart disease (high blood pressure) and kidney failure (kidneys unable to work). During a concurrent interview and record review on 1/15/2026, at 4:08 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 1’s Plan of Care for certification period 11/16/2025 to 1/14/2026. The POC indicated, “SN (skilled nurse) to monitor blood sugar level every visit and monitor for s/s (signs and symptoms) of hypo/hyperglycemia (hypoglycemia-low blood sugar, hyperglycemia-high blood sugar). RN 2 stated the intervention forementioned meant that the SN was supposed to assess and ask the patient if the patient was feeling dizzy, feeling hot, had a headache, or was clammy. Based on what the patient answered, the SN could determine what the patient was having: hyper or hypoglycemia. Monitoring blood sugar levels also meant that the nurse needed to document that hyper/hypoglycemia was assessed and what the patient reported. If there was no problem, this needed to be documented as well. During a concurrent interview and record review on 1/15/2026, at 4:08 p.m., with RN 2, RN 2 reviewed Patient 1’s Skilled Nursing visit dated 11/18/2025. RN 2 stated the record did not indicate the SN monitored Patient 1 for hypo/hyper glycemia. RN 2 stated the importance of documenting Patient 1 was monitored, was to know Patient 1 was not having any symptoms of blood sugar problems or complications of diabetes, to avoid hospitalization due to complications. RN 2 continued to review Patient 1’s Skilled Nursing notes dated 11/25/2025, 12/4/2025, 12/19/2025, 12/23/2025, and 1/2/2026. RN 2 stated the SN did not monitor Patient 1 for signs and symptoms of hypo/hyperglycemia. During an interview on 1/15/2026, at 4:20 p.m., with RN 2, RN 2 stated Patient 1’s POC was not followed consistently. The importance of following the POC was to make sure the patient was given proper care, to make sure patient was being monitored on time, if there was a problem, it was addressed appropriately. 2. During a record review of Patient 3’s Patient Information sheet, indicated a start of care of 7/6/2025, with a primary diagnosis of heart failure (heart unable to pump blood effectively to the body). During an interview on 1/15/2026, at 4:32 p.m., with Registered Nurse 2 (RN 2), RN 2 stated the recertification assessment was used to give time for the plan of care to be done for the next certification period, so the nurse knows what needs to be done for the patient. RN 2 stated the assessment identifies what the new problems are, what the medications are, and any issues that warrant interventions for the plan of care. During a concurrent interview and record review on 1/15/2026, at 4:33 p.m., with RN 2, RN 2 reviewed Patient 3’s medical records. The medical records did not indicate a plan of care for recertification period 1/2/2026 to 3/2/2026. RN 2 stated there was no plan of care documented. Further review of the Patient 3’s records indicated Patient 3 had received two nursing visits: 1/7/2026 and 1/13/2026. RN 2 stated there was no communication note to validate that the Skilled Nurse was told what the plan of care was for Patient 3. RN 2 stated the risk of providing care without a plan of care was: the HHA was not providing the proper care, based on the problems identified in the recertification assessment. If Patient 3 had new medications, a skin problem or any other issues, it would not be addressed because there was no plan of care. Issues that are not addressed placed Patient 3 at risk of hospitalization, risk of harm, risk of falls, if there were skin problems, these can worsen. RN 2 stated based on the information of the previous certification period, Patient 3 had congestive heart failure, and was at risk of harm. The patient could have shortness of breath, edema (swelling), muscle weakness, which could cause falls. 3. During a record review of Patient 5’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/15/2025 with a primary diagnosis of age-related osteoporosis (brittle and fragile bones) without current pathological fracture. During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” indicated it was dated from 11/15/2025 to 1/13/2026. During a record review on 1/15/2026 at 4:07 p.m. of Patient 5’s medical record, the medical record indicated Patient 5’s plan of care was “not yet due” for service period 1/14/2026 to 3/14/2026. During a joint home visit on 1/14/2026 at 12 p.m. with Licensed Vocational Nurse 1 (LVN1) at Patient 5’s residence, LVN1 assessed Patient 5 using Patient 5’s plan of care dated 11/15/2025 to 1/13/2026. During a concurrent interview and record review on 1/20/2026 at 11:55 a.m. with Registered Nurse 2 (RN2) of Patient 5’s medical record, RN2 stated that there is no care plan formulated for Patient 5 during the current service period of 1/14/2026 to 3/14/2026. RN2 stated nurses use patients care plans as a guide, to guide them on the care needed by the patient. RN2 stated care plans were important for the nurses to be able to provide quality patient care and to prevent errors. RN2 stated that patients plan of care was doctors order for care. During a record review of the HHA’s document titled, Plan of Treatment, dated 2025, indicated, “POT (Plan of Treatment) is strictly followed by the Discipline for the defined 60-day period.”

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 – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to include information required in the Plan of Care (POC) for one of seven sampled patients (Patient 1). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. 1a. During a record review of Patient 1’ Patient Information sheet, indicated a start of care of 3/21/2025, with primary diagnoses including hypertensive heart disease (high blood pressure) and kidney failure (kidneys unable to work). During a concurrent interview and record review on 1/20/2026, at 1:30 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 1’s initial comprehensive assessment titled, OASIS-E1 Start of Care, dated 3/21/2025. The record indicated Patient 1 had an AV graft (a surgically placed tube into the artery and vein. Used for dialysis-a process to remove waste from the blood) on the left arm. RN 2 stated the AV graft assessment finding required interventions in the POC. The interventions needed were to assess the AV graft for signs of bleeding, presence of a bruit (to make sure it is working properly), pain or discomfort, and guidance not to take the blood pressure on the left side. Taking the blood pressure on the left side could affect the patency, circulation and effectiveness of the AV graft. The patient could lose the ability to have dialysis done. During a concurrent interview and record review on 1/20/2026, at 1:35 p.m., with RN 2, RN 2 reviewed Patient 1’s POC, for certification period 3/21/2025 to 5/19/2025. RN 2 stated the record did not indicate any interventions for Patient 1’s AV graft. During a concurrent interview and record review on 1/20/2026, at 1:38p.m., with RN 2, RN 2 reviewed Patient 1’s recertification assessment titled, OASIS-E1 Recertification, dated 11/13/2025. RN 2 stated the record indicated Patient 1 had an AV graft on the left arm. RN 2 stated interventions were needed in the POC for certification period 11/16/2025 to 1/14/2026. RN 2 then reviewed Patient 1’s POC for certification period 11/16/2025 to 1/14/2026 and stated the POC did not have any interventions for the AV graft. During a record review of Patient 1’s Skilled Nursing visit note, dated 1/6/2025, indicated the nurse had taken Patient 1’s blood pressure on the left arm. 1b. During a concurrent interview and record review on 1/14/2026, at 11:20 a.m., with the Administrator (ADM), the ADM reviewed Patient 1’s record titled, Acknowledgement of Receipt of Advance Directive Information, dated 3/21/2025. The record indicated, “I have executed the following Advance Directives: Living Will…Durable Power of Attorney/Proxy.” The ADM stated the HHA did not retain a copy of Patient 1’s advance directive and did not know the reason why. During an interview on 1/15/2026, at 4:04 p.m., with RN 2, RN 2 stated the HHA should have obtained a copy of the advance directive, so staff know what needs to be done in case of an emergency, and to follow what is written on the record. RN 2 stated the copy of the advance directive should have been in Patient 1’s medical records. During a record review of Patient 1’s POC, dated 11/16/2025 to 1/14/2026, indicated, “Advance Directives? No”. During a record review of the HHA’s document titled, Advance Directive, dated 2025, did not indicate a process for what is to be done when a patient has an Advance Directive. During a record review of the HHA’s document titled, Plan of Treatment, dated 2025, indicated, “POT (Plan of Treatment) is to be based on the Initial Evaluation performed.”

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to include information required in the Plan of Care (POC) for one of seven sampled patients (Patient 1). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. 1. During a record review of Patient 3’s Patient Information sheet, indicated a start of care of 7/6/2025, with a primary diagnosis of heart failure (heart unable to pump blood effectively to the body). During a concurrent interview and record review on 1/15/2026, at 4:24 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 3’s record titled, Physician Order, dated 12/30/2025. The record indicated an order to recertify Patient 3 for HHA services for certification period 1/2/2026 to 3/2/2026. Further review of the record did not indicate a signature to validate who had taken then order. RN 2 stated the order was not complete because there was no order or the plan of care for the nurses to follow. RN 2 stated she did not know who created the order because the record was not signed. During a concurrent interview and record review on 1/15/2026, at 4:33 p.m., with RN 2, RN 2 reviewed Patient 3’s medical records. The medical records did not indicate a plan of care for recertification period 1/2/2026 to 3/2/2026. RN 2 stated there was no plan of care documented. Further review of the Patient 3’s records indicated Patient 3 had received two nursing visits: 1/7/2026 and 1/13/2026. RN 2 stated there was no communication note to validate that the Skilled Nurse was told what the plan of care was for Patient 3. RN 2 stated the risk of providing care without a plan of care was: the HHA was not providing the proper care, based on the problems identified in the recertification assessment. If Patient 3 had new medications, a skin problem or any other issues, it would not be addressed because there was no plan of care. Issues that are not addressed placed Patient 3 at risk of hospitalization, risk of harm, risk of falls, if there were skin problems, these can worsen. RN 2 stated based on the information of the previous certification period, Patient 3 had congestive heart failure, and was at risk of harm. The patient could have shortness of breath, edema (swelling), muscle weakness, which could cause falls. During a record review of Patient 3’s task details report (a report that tracks when documentation is entered and edited), indicated the Quality Assurance staff (QA) created the order on 1/14/2026. During an interview on 1/20/2026, at 1:06 p.m., with the Administrator (ADM), the ADM stated the QA staff typed whatever the Case Manager (CM 1) told her, to facilitate and get documentation started. The ADM stated the QA staff was not a licensed nurse. During an interview on 1/20/2026, at 2:05 p.m., with the QA staff, the QA stated her role included checking documentation for mistakes and missing entries. The QA staff stated she sometimes corrected documentation if the staff told her to do it because “most of the time the staff will tell me they don’t have time to correct the documentation. So, I will correct it for them, with their permission.” The QA staff stated once the documentation is corrected, she sent document for the staff to review and sign. The QA stated the CM 1 will write down the order on a piece of paper and give it to her to help put the order in the medical record. During an interview on 1/20/2026, at 2:12 p.m., with the CM 1, CM 1 stated the QA staff begins to document the order, then the CM 1 goes back to complete the order and make sure it is correct. CM 1 stated the QA staff enters the order is because CM 1 gets behind in her work. CM 1 stated the person who takes the order needed to enter the order in the patient medical record to ensure the accuracy of the order taken. If the order is transcribed incorrectly there can be issues with proper care and complications. During a record review of the HHA’s document titled, Physician Orders, dated 2025, the record indicated, “Verbal orders may be accepted by a licensed clinician when necessary. The clinician shall: Document the verbal order, include the date and name of the ordering physician.”

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 observation, interview and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure the physician was informed of one of seven sample patients (Patient 5) change of condition. This failure had the potential to result in the patient being hospitalized due to low blood pressure and/or HHA staff is not aware of the patient's status. During a record review of Patient 5’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/15/2025 with a primary diagnosis of age-related osteoporosis (brittle and fragile bones) without current pathological fracture. During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 11/15/2025 to 1/13/2026, indicated “Notify physician of: Systolic BP greater than (>) 160 or less than ()90 or less than (<) 60.” During a joint home visit on 1/14/2026 at 12 p.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 5’s residence, LVN1 assessed Patient 5’s blood pressure with a reading of 80/41. LVN1 stated that Patient 5’s regular nurse informed her (LVN1) that Patient 5’s blood pressure is always low. LVN1 stated that she (LVN1) did not “think” Patient 5’s low blood pressure reading was an issue. LVN1 was not noted informing the HHA or Patient 5’s physician of the low blood pressure reading. During a concurrent interview and record review on 1/15/2026 at 3:21 p.m. with Registered Nurse 2 (RN2) of Patient 5’s medical record, RN2 stated that Patient 5’s physician should have been made aware of the low blood pressure reading to prevent further decline that could result in hospitalization. RN2 stated that Patient 5 had the possibility of experiencing dizziness, falls, and stoke due to the low blood pressure. RN2 stated that it was important to follow Patient 5’s care plan to provide proper care and assessment. During a record review of the HHA’s document titled, Significant Change in Condition, dated 2025, indicated, “Significant Change in Condition (SCIC): A major decline or improvement in a patient’s health status that...Impacts the patient’s functional, cognitive, psychosocial, or medical status...Any staff member identifying a potential significant change in condition shall report it promptly...The physician shall be notified of the significant change in condition.”

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure the physician was informed of the three of seven sample patients (Patient 2, Patient 6 and Patient 7) were discharged. This failure had the potential to result in patients do not receive services that can potentially be detrimental to their health. 1. During a record review of Patient 2’s Patient Information sheet, indicated a start of care of 8/11/2025, with a primary diagnosis of bilateral (both sides) osteoarthritis (arthritis-stiffening of the joints) of the hip. During a record review of Patient 2’s Physician Order, dated 12/5/2026, the record indicated Patient 2 was to be discharged from home health services. During a concurrent interview and record review on 1/20/2026, at 1:47 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 2’s Physician Order, dated 12/5/2025. The record indicated the order was received on 1/14/2026. Further review of the record indicated Patient 2 was hospitalized on 12/7/2025. RN 2 was asked why the discharge order was written on 1/14/2026 but dated 12/5/2025 (patient was hospitalized per the note on 12/7/2025). RN 2 stated she did not know and could not answer for that. The discharge order was supposed to be entered on the same day she found out the patient was hospitalized, 12/7/2025. RN 2 stated there was no documentation to support the doctor was notified of the hospitalization and discharge from HHA services. RN 2 stated it was not clear when the doctor was notified. 2. During a record review of Patient 6’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/20/2024 with a primary diagnosis of other intervertebral disc degeneration lumbar region with back & lower extremity pain. During a record review on 1/15/2026 at 4:40 p.m., of Patient 6’s medical record, the medical record indicated there was one physician order in Patient 6’s record. During a record review of Patient 6’s medical record form titled “Physician Order” dated 12/22/2025, indicated Patient 6 was to be discharge from HH services. The form also indicated it was digitally signed by the Case Manager 1 (CM1) and the Director of Patient Care Services (DPCS) on 12/22/2025. During a record review of Patient 6’s medical record form titled “Task Details – Physician Order” undated, indicated it was created and completed on 1/14/2026 by the CM1. During a concurrent interview and record review on 1/20/2026 at 12:36 p.m., with Registered Nurse 2 (RN2) of Patient 6’s medical record, RN2 stated that Patient 6 was discharged on 12/22/2025. Upon further review, RN2 stated that Patient 6’s discharge order was created on 1/14/2026, therefore as far as she (RN2) knows Patient 6’s physician was made aware of her (Patient 6) discharge on 1/14/2026. 3. During a record review of Patient 7’s medical record form titled “Patient Information” undated, indicated a start of care date of 5/24/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar) without complications. During a record review on 1/15/2026 at 10:11 a.m. of Patient 7’s medical record, the medical record indicated there was one physician order in Patient 7’s record. During a record review of Patient 7’s medical record form titled “Physician Order” dated 12/18/2025, indicated Patient 7 was to be discharge from HH services. The form also indicated it was entered and digitally signed by the Case Manager 1 (CM1) on 12/18/2025. During a record review of Patient 7’s medical record form titled “Task Details – Physician Order” undated, indicated it was the task details of Patient 7’s physician order. The Task Detail form also indicated it was created and completed on 1/13/2026 by the CM1. During a record review of Patient 7’s medical record form titled “Patient Communication” dated 12/18/2025, indicated Patient 7 was to be discharge from HH services due to moving to Mexico. The form also indicated the medical doctor was made aware. Lastly, the form indicated it was entered and digitally signed by the Case Manager 1 (CM1) on 12/18/2025. During a record review of Patient 7’s medical record form titled “Task Details – Patient Communication” undated, indicated it was created on 1/13/2026 and completed on 1/14/2026 by the CM1. During a concurrent interview and record review on 1/20/2026 at 12:27 p.m., with Registered Nurse 2 (RN2) of Patient 7’s medical record, RN2 stated that according to Patient 7’s discharge order it was written on 12/18/2025. After reviewing further, RN2 stated that Patient 7’s discharge order and communication note that stated the doctor was made aware, were created on 1/13/2026 by Case Manager 1 (CM1). RN2 stated that since Patient 7’s discharge order and communication note were created on 1/13/2026, then that was the date his (Patient 7) doctor was made aware of his (Patient 7) discharge. RN2 stated it was important to inform physicians when a patient was discharged to be aware that the patient was no longer receiving HH services. RN2 stated physicians also need to be made aware to be able to continue the patients care. During an interview on 1/20/2026 at 2:11 p.m., with the Case Manager 1 (CM1), CM1 stated she was responsible for transcribing physician orders and documents into patients' medical records. CM1 stated she writes notes to remind herself what needs to be input into the patients’ medical records. CM1 stated she was busy and that it may take up to a month to transcribe physician orders or notes into the patients’ medical record and that it was not an acceptable practice. CM1 stated that an assumption is made that a document was entered and created on the date that is documented, and in actuality it was entered on a different date. During a review of the HHA’s document titled, Discharge Policy, dated 2025, the record indicated, “For planned discharges, CNHHA shall...Notify the physician of discharge...Unplanned discharge process for unplanned discharged, CNHHS shall...Notify the physician when possible.”

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patients personal residence) failed to ensure the Condition of Participation for Quality Assessment and Performance Improvement (QAPI), the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance and Performance Improvement (QAPI) were met as follows: The HHA failed to have the 2025 Quality Assessment and Performance Improvement (QAPI) program that include procedure for measurement and analysis of indicators and address the frequency which measurement and analysis. This deficiency practice resulted in the inability of the agency to identify issue, improve health outcomes, patient safety, and quality of care. (Refer to 642). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulation for Quality Assessment and Performance Improvement (QAPI) program to ensure the provision of the highest quality of care to patients in a safe environment.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to have the 2025 Quality Assessment and Performance Improvement (QAPI) program that include procedure for measurement and analysis of indicators and address the frequency which measurement and analysis. This deficient practice resulted in the inability of the agency to identify issue, improve health outcomes, patient safety, and quality of care. During an interview on 1/20/2026, at 11 a.m., with the Administrator (ADM), the ADM stated the HHA had QAPI meetings a needed, every week to two weeks. The ADM stated the issues the HHA was working on was patient coordination, but it was hard to grasp on one specific topic. The ADM stated the QAPI meetings were not documented: there were no meeting agendas, no sign in sheets, no meeting minutes. The ADM was asked how the HHA was tracking information on the QAPI program. The ADM stated he produced reports for the period that was being reviewed. During the survey, the ADM was unable to show any documentation related to projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on the projects. During a record review of the HHA’s document titled, Quality Assessment & Performance Improvement, dated 2018, indicated, “Responsibilities include: Quarterly review of quality data, Approval of PIP’s and corrective actions...QAPI Meetings & Documentation: Routine internal review by Administrator and DON, Governing Body approval recorded, Records retained per CM and CDPH requirements.”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure two of seven sample patients (Patient 4 and Patient 5) Certified Home Health Aides (CHHA) were supervised for care they were providing. This failure had the potential to result in endangering patients' health and wellbeing. 1. During a record review of Patient 4’s medical record form titled “Patient Information” undated, indicated a start of care date of 8/16/2025 with a primary diagnosis of essential hypertension (high blood pressure). During a concurrent interview and record review on 1/15/2026 at 2:50 p.m., with Registered Nurse 2 (RN2) of Patient 4’s medical record, RN2 stated Patient 4 was receiving CHHA services twice a week. RN2 stated CHHA supervisory visits are to be conducted every two weeks to ensure the CHHA is following Patient 4’s care plan. RN2 stated CHHA supervisor visits are performed to address any issues with the care or with the patient's expectation of the CHHAs care. RN2 stated that without CHHA supervisory visits the HHA does not know if the patient has any concerns or issues with the CHHA. 2. During a record review of Patient 5’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/15/2025 with a primary diagnosis of age-related osteoporosis (brittle and fragile bones) without current pathological fracture. During a record review of Patient 5’s medical record titled “Task Details – Aide Supervisory Visit” dated 12/6/2025 and 12/20/2025, indicated both records were created and completed on 1/13/2026. During a concurrent interview and record review on 1/15/2026 at 3:21 p.m., with Registered Nurse 2 (RN2) of Patient 5’s medical record, RN2 stated Patient 5 was receiving CHHA services twice a week. RN2 stated Patient 5’s CHHA was last supervised on 12/20/2025, according to the medical record. Further review of Patient 5’s record, the record indicated the supervisory notes dated 12/6/2025 and 12/20/2025 were both created and completed on 1/13/2026. RN2 stated she was unable to validate if Patient 5’s CHHA ever had a supervisory visit. RN2 stated CHHA supervisory visits are to be conducted to ensure patient was satisfied with the care being provided, and the plan of care is being followed. During a record review of the HHA’s document titled, Certified Home Health Aide (CHHA) Supervisory Visits Policy, dated 2025, indicated, “California Nurses Home Health Services shall conduct supervisory visits of all CHHAs to evaluate the quality of care provided, ensure compliance with the Plan of Care, and assess patient satisfaction and needs. Supervisory visits shall be performed by a qualified Registered Nurse (RN) or other qualified professional in accordance with federal regulations...Supervisory visits shall be conducted at least every two (2) weeks when CHHA services are provided...Findings shall be documented and communicated to the CHHA and clinical management.”

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 interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1. The HHA failed to ensure three of seven sampled patients (Patient 2, Patient 3, and Patient 5) clinical records included assessments, plan of care, and doctor’s orders. This failure resulted in an incomplete clinical record. (Refer to G1012). 2. The HHA failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for three of seven sampled patients (Patient 2, Patient 6 and Patient 7). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. (Refer to G1022). 3. The HHA failed to ensure patient care records were complete and authenticated for three of seven sampled patients (Patient 3, Patient 6 and Patient 7). This failure resulted in patients’ medical records being modified by people not involved in patients’ care. (Refer to G1024). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of quality health care in a safe environment.

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 interviews and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure three of seven sampled patients (Patient 2, Patient 3, and Patient 5) clinical records included assessments, plan of care, and doctor’s orders. This failure resulted in an incomplete clinical record. 1. During a record review of Patient 2’s Patient Information sheet, indicated a start of care of 8/11/2025, with a primary diagnosis of bilateral (both sides) osteoarthritis (arthritis-stiffening of the joints) of the hip. During a record review of Patient 2’s Physician Order, dated 12/5/2026, the record indicated Patient 2 was to be discharged from home health services. During a concurrent interview and record review on 1/20/2026, at 1:47 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 2’s Physician Order, dated 12/5/2025. The record indicated the order was received on 1/14/2026. Further review of the record indicated Patient 2 was hospitalized on 12/7/2025. RN 2 was asked why the discharge order was written on 1/14/2026, but dated 12/5/2025 (patient was hospitalized per the note on 12/7/2025). RN 2 stated she did not know and could not answer for that. The discharge order was supposed to be entered on the same day she found out the patient was hospitalized, 12/7/2025. RN 2 stated there was no documentation to support the doctor was notified of the hospitalization and discharge from HHA services. During a concurrent interview and record review on 1/20/2026, at 1:54 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 2’s medical records. The records indicated an OASIS-E1 transfer was documented on 12/5/2025. RN 2 stated Patient 2’s order was to discharge; therefore, a discharge assessment was required. RN 2 stated she did not know why a discharge assessment was not done. 2. During a record review of Patient 3’s Patient Information sheet, indicated a start of care of 7/6/2025, with a primary diagnosis of heart failure (heart unable to pump blood effectively to the body). During a record review of Patient 3’s medical records, on 1/14/2026, there was no recertification assessment for the certification period 1/2/2026 to 3/2/2026. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 1/15/2026 at 4:30 p.m., RN 2 reviewed Patient 3’s medical records and stated record titled, OASIS recertification assessment, dated 12/30/2025 was in Patient 3’s records. RN 2 stated this was the assessment used to recertify Patient 3 for period 1/2/2026 to 3/2/2026. During a concurrent interview and record review with the administrator (ADM) on 1/15/2026, at 4:31 p.m., the ADM reviewed the task details report (a report that tracks when documentation is entered and edited) for Patient 3’s record titled, OASIS recertification assessment, dated 12/30/2025. The ADM stated the OASIS recertification assessment dated 12/30/2025 was entered into Patient 3’s medical records on 1/14/2026. During an interview on 1/15/2026, at 4:32 p.m., with RN 2, RN 2 stated the recertification assessment should have been done 5 days prior to the new certification period. In this case, on 12/28/2025. The reason it should have been done was to give time for the plan of care to be done for the next certification period, so the nurse knows what needs to be done for the patient. RN 2 stated the assessment identifies what the new problems are, what the medications are, and any issues that warrant interventions for the plan of care. During a concurrent interview and record review on 1/15/2026, at 4:33 p.m., with RN 2, RN 2 reviewed Patient 3’s medical records. The medical records did not indicate a plan of care for recertification period 1/2/2026 to 3/2/2026. RN 2 stated there was no plan of care documented. Further review of the Patient 3’s records indicated Patient 3 had received two nursing visits: 1/7/2026 and 1/13/2026. RN 2 stated there was no communication note to validate that the Skilled Nurse was told what the plan of care was for Patient 3. RN 2 stated the risk of providing care without a plan of care was: the HHA was not providing the proper care, based on the problems identified in the recertification assessment. If Patient 3 had new medications, a skin problem or any other issues, it would not be addressed because there was no plan of care. Issues that are not addressed placed Patient 3 at risk of hospitalization, risk of harm, risk of falls, if there were skin problems, these can worsen. RN 2 stated based on the information of the previous certification period, Patient 3 had congestive heart failure, and was at risk of harm. The patient could have shortness of breath, edema (swelling), muscle weakness, which could cause falls. 3. During a record review of Patient 5’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/15/2025 with a primary diagnosis of age-related osteoporosis (brittle and fragile bones) without current pathological fracture. During a record review on 1/20/2026 at 10:30 a.m. of Patient 5’s medical record, the medical record indicated Patient 5’s certification period from 11/15/2025 to 1/13/2026, scheduled recertification assessment dated for 1/10/2026, was “not started”. During a record review on 1/20/2026 at 10:30 a.m. of Patient 5’s medical record, the medical record did not indicate Patient 5 had a recertification assessment completed for certification period from 1/14/2026 to 3/14/2026. During a concurrent interview and record review on 1/20/2026 at 11:55 a.m. with Registered Nurse 2 (RN2) of Patient 5’s medical record, RN2 stated there was no documented recertification assessment for Patient 5’s certification period 1/14/2026 to 3/14/2026. RN2 stated that a rectification assessment evaluates the needs to continue HH services, to provide proper quality of care, and treatment. RN2 stated that she (RN2) does not know if Patient 5 qualifies for HH services at this time. During a record review of the HHA’s document titled, Clinical Documents Policy, dated 2025, indicated, “California Nurses Home Health Services’ patient care activities, assessments, physician orders, and visits should be documented in CNHHS’s electronic health record (WellSky Home Health) and the hard-copy chart is also filed with Medical Records.”

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 (HHA – an organization that delivers skilled nursing and other therapeutic services to patients' personal residence) failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for three of seven sampled patients (Patient 2, Patient 6 and Patient 7). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. 1. During a record review of Patient 2’s Patient Information sheet, indicated a start of care of 8/11/2025, with a primary diagnosis of bilateral (both sides) osteoarthritis (arthritis-stiffening of the joints) of the hip. During a record review of Patient 2’s Physician Order, dated 12/5/2026, the record indicated Patient 2 was to be discharged from home health services. During a concurrent interview and record review on 1/20/2026, at 1:54 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 2’s medical records. The records indicated an OASIS-E1 transfer was documented on 12/5/2025. RN 2 stated Patient 2’s order was to discharge; therefore, a discharge assessment was required. RN 2 stated she did not know why a discharge assessment was not done. 2. During a record review of Patient 6’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/20/2024 with a primary diagnosis of other intervertebral disc degeneration lumbar region with back & lower extremity pain. During a record review on 1/15/2026 at 4:40 p.m. of Patient 6’s medical record, the medical record indicated there was one physician order in Patient 6’s record. During a record review of Patient 6’s medical record form titled “Physician Order” dated 12/22/2025, indicated Patient 6 was to be discharge from HH services. The form also indicated it was digitally signed by the Case Manager 1 (CM1) and the Director of Patient Care Services (DPCS) on 12/22/2025. During a record review of Patient 6’s medical record form titled “Task Details – Physician Order” undated, indicated it was created and completed on 1/14/2026 by the CM1. During a concurrent interview and record review on 1/20/2026 at 12:36 p.m. with Registered Nurse 2 (RN2) of Patient 6’s medical record, RN2 stated that Patient 6 was discharged on 12/22/2025. Upon further review, RN2 stated that Patient 6’s discharge order was created on 1/14/2026, therefore as far as she (RN2) knows Patient 6’s physician was made aware of her (Patient 6) discharge on 1/14/2026. 2. During a record review of Patient 7’s medical record form titled “Patient Information” undated, indicated a start of care date of 5/24/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar) without complications. During a record review on 1/15/2026 at 10:11 a.m. of Patient 7’s medical record, the medical record indicated there was one physician order in Patient 7’s record. During a record review of Patient 7’s medical record form titled “Physician Order” dated 12/18/2025, indicated Patient 7 was to be discharge from HH services. The form also indicated it was entered and digitally signed by the Case Manager 1 (CM1) on 12/18/2025. During a record review of Patient 7’s medical record form titled “Task Details – Physician Order” undated, indicated it was the task details of Patient 7’s physician order. The Task Detail form also indicated it was created and completed on 1/13/2026 by the CM1. During a record review of Patient 7’s medical record form titled “Patient Communication” dated 12/18/2025, indicated Patient 7 was to be discharge from HH services due to moving to Mexico. The form also indicated the medical doctor was made aware. Lastly, the form indicated it was entered and digitally signed by the Case Manager 1 (CM1) on 12/18/2025. During a record review of Patient 7’s medical record form titled “Task Details – Patient Communication” undated, indicated it was created on 1/13/2026 and completed on 1/14/2026 by the CM1. During a concurrent interview and record review on 1/20/2026 at 12:27 p.m. with Registered Nurse 2 (RN2) of Patient 7’s medical record, RN2 stated that according to Patient 7’s discharge order it was written on 12/18/2025. After reviewing further, RN2 stated that Patient 7’s discharge order and communication note that stated the doctor was made aware, were created on 1/13/2026 by Case Manager 1 (CM1). RN2 stated that since Patient 7’s discharge order and communication note were created on 1/13/2026, then that was the date his (Patient 7) doctor was made aware of his (Patient 7) discharge. RN2 stated it was important to inform physicians when a patient is discharged to be aware that the patient is no longer receiving HH services. RN2 stated physicians also need to be made aware to be able to continue the patients care. During an interview on 1/20/2026 at 2:11 p.m. with the Case Manager 1 (CM1), CM1 stated that she (CM1) is responsible for transcribing physician orders and documents into patients' medical records. CM1 stated that she (CM1) writes notes to remind herself (CM1) what needs to be input into the patients’ medical records. CM1 stated that she (CM1) is busy and that it may take up to a month to transcribe physician orders or notes into the patients’ medical record and that it was not an acceptable practice. CM1 stated that an assumption is made that a document was entered and created on the date that is documented, and in actuality it was entered on a different date. During a review of the HHA’s document titled, Discharge Policy, dated 2025, the record indicated, “For planned discharges, CNHHA shall......Notify the physician of discharge... Complete a discharge assessment and summary...Unplanned discharge process for unplanned discharged, CNHHS shall...Notify the physician when possible....Discharge documentation...Discharge summary.”

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 (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence) failed to ensure patient care records were complete and authenticated for three of seven sampled patients (Patient 3, Patient 6 and Patient 7). This failure resulted in patients’ medical records being modified by people not involved or authorized in patients’ care and services. 1. During a record review of Patient 3’s Patient Information sheet, indicated a start of care of 7/6/2025, with a primary diagnosis of heart failure (heart unable to pump blood effectively to the body). During a concurrent interview and record review on 1/15/2026, at 4:24 p.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 3’s record titled, Physician Order, dated 12/30/2025. The record indicated an order to recertify Patient 3 for HHA services for certification period 1/2/2026 to 3/2/2026. Further review of the record did not indicate a signature to validate who had taken the order. RN 2 stated the order was not complete because there was no order or the plan of care for the nurses to follow. RN 2 stated she did not know who created the order because the record was not signed. During a record review of Patient 3’s task details report (a report that tracks when documentation is entered and edited), indicated the Quality Assurance staff (QA) created the order on 1/14/2026. During an interview on 1/20/2026, at 1:06 p.m., with the Administrator (ADM), the ADM stated the QA staff typed whatever the Case Manager (CM 1) told her, to facilitate and get documentation started. The ADM stated the QA staff was not a licensed nurse. During an interview on 1/20/2026, at 2:05 p.m., with the QA staff, the QA stated her role included checking documentation for mistakes and missing entries. The QA staff stated she sometimes corrected documentation if the staff told her to do it because “most of the time the staff will tell me they don’t have time to correct the documentation. So, I will correct it for them, with their permission.” The QA staff stated once the documentation is corrected, she sent document for the staff to review and sign. The QA stated the CM 1 will write down the order on a piece of paper and give it to her to help put the order in the medical record. During an interview on 1/20/2026, at 2:12 p.m., with the CM 1, CM 1 stated the QA staff begins to document the order, then the CM 1 goes back to complete the order and make sure it is correct. CM 1 stated the QA staff enters the order is because CM 1 gets behind in her work. CM 1 stated the person who takes the order needed to enter the order in the patient medical record to ensure the accuracy of the order taken. If the order is transcribed incorrectly there can be issues with proper care and complications. 2. During a record review of Patient 6’s medical record form titled “Patient Information” undated, indicated a start of care date of 11/20/2024 with a primary diagnosis of other intervertebral disc degeneration lumbar region with back & lower extremity pain. During a record review of Patient 6’s medical record form titled “Physician Order” dated 12/22/2025, indicated Patient 6 was to be discharge from HH services. The form also indicated it was digitally signed by the Case Manager 1 (CM1) and the Director of Patient Care Services (DPCS) on 12/22/2025. During a record review of Patient 6’s medical record form titled “Task Details – Physician Order” undated, indicated it was created and completed on 1/14/2026 by the CM1. 3. During a record review of Patient 7’s medical record form titled “Patient Information” undated, indicated a start of care date of 5/24/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar) without complications. During a record review of Patient 7’s medical record form titled “OASIS-E1 Discharge (Non-Billable)” dated 12/18/2025, indicated the assessment was completed on 12/18/2025. The assessment does not indicate the authors name or signature. During a record review of Patient 7’s medical record form titled “Physician Order” dated 12/18/2025, indicated Patient 7 was to be discharge from HH services. The form also indicated it was entered and digitally signed by the Case Manager 1 (CM1) on 12/18/2025. During a record review of Patient 7’s medical record form titled “Task Details – Physician Order” undated, indicated it was the task details of Patient 7’s physician order. The Task Detail form also indicated it was created and completed on 1/13/2026 by the CM1. During a record review of Patient 7’s medical record form titled “Patient Communication” dated 12/18/2025, indicated Patient 7 was to be discharge from HH services due to moving to Mexico. The form also indicated the medical doctor was made aware. Lastly, the form indicated it was entered and digitally signed by the Case Manager 1 (CM1) on 12/18/2025. During a record review of Patient 7’s medical record form titled “Task Details – Patient Communication” undated, indicated it was created on 1/13/2026 and completed on 1/14/2026 by the CM1. During an interview on 1/20/2026 at 2:11 p.m., with the Case Manager 1 (CM1), CM1 stated that she was responsible for transcribing physician orders and documents into patients' medical records. CM1 stated she writes notes to remind herself what needs to be input into the patients’ medical records. CM1 stated that she was busy and that it may take up to a month to transcribe physician orders or notes into the patients’ medical record and that it was not an acceptable practice. CM1 stated that an assumption is made that a document was entered and created on the date that is documented, and in actuality it was entered on a different date. During a record review of the HHA’s document titled, Clinical Documents Policy, dated 2025, indicated, “Clinical records must be accurate, complete, authenticated by the responsible clinician, and amended in a controlled manner when corrections are necessary.”

The following reflects the findings of the Department of Public Health during a Recertification Survey.Representing the Department of Public HealthSurveyor ID #- 25046 RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions -48Active Patients -17Sample Size -7 PatientsHome Visit - 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the emergency preparedness plan and training for staff were done on an annual basis. This failure had the potential for the staffs to have a lack of knowledge to respond effectively during an emergency situation. During a review of the emergency preparedness plan and disaster training of the HHA on 3/27/22 at 11:30 a.m., the HHA did not have evidence of Emergency Preparedness training/Disaster drill for all staff and did not have evidence of emergency plan annual review. During an interview with the Administrator (ADM) on 3/27/22 at 11:51 p.m., the ADM stated that the Emergency preparedness/Disaster drill training had not been done with staff annually. There was no documented evidence the governing body reviewed the policy annually on Emergency Preparedness/Disaster. The HHA's undated policy and procedure titled, "Emergency Preparedness Plan" indicated “this emergency preparedness plan was designed to provide continuing care/service in the event of an emergency that would result in interruption of patient care services.”

The following reflects the findings of the Department of Public Health during a Recertification Survey.Representing the Department of Public HealthSurveyor ID #- 25046 RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions -48Active Patients -17Sample Size -7 PatientsHome Visit - 3

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 ensure the patients' current medication profile match the medications the patients taking at home for two of seven patients (Patients 2 and 4 ). This failure had the potential to place the patients at risk for medication errors and adverse drug reactions. A review of Patient 4’s Patient Information indicated, a star of care (SOC) date of 3/10/22, with diagnoses including aphasia (loss of ability to understand or express speech, caused by brain damage) and pressure ulcer of left hip stage 2 (partial thickness skin loss). During a review of Patient 4’s Plan of Care (POC), for the certification period from 3/10/22 to 5/8/22, included an order for skilled nurse (SN) to visit twice a week for two weeks. The POC indicated the SN was to review the patient’s medication regimen and provide education. Patient 4’s medication profile dated 3/10/22, included Eliquis (medication to prevent blood clots) 2.5 mg (mg-milligram unit of measurement) 1 tablet twice a day. The profile also included Losartan Potassium (medication for blood pressure) 50 mg 1 tablet daily. During an observation of a home visit on 3/26/22, at 2:06 p.m., Licensed Vocational Nurse (LVN) was observed providing care to Patient 4. During an interview on 3/26/22, at 2:40 p.m., LVN stated she did not check the medications Patient 4 was taking because she had checked them on the visit done on Monday. LVN stated medications are supposed to be reviewed and ensure the medication patient is taking match the medication profile, every visit. LVN stated checking medications every visit is important because there could be changes that could impact the care of the patient. A review of the HHA’s undated policy and procedure titled, “Administration of Medications”, indicated “Registered Nurses and Licensed Vocational Nurses will review the patient’s medication on a routine basis or as ordered within the Plan of Care”. a. A review of Patient 2's clinical record indicated a start of care dated 8/18/21, with primary diagnosis of osteoporosis (a condition in which bones become weak and brittle).A review of Patient 2's plan of care from 2/14/22 to 4/14/22, included an order for SN (skilled nurse) visits of once a week for nine weeks. The SN was to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication, and compliance. SN was also to instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). On 3/26/22, at 11 a.m., a home visit was conducted at Patient 2's residence with LVN 2. Patient 2 was observed sitting on the chair in the living room. During a review of Patient 2's medications indicated a bottle of Furosemide 20 milligrams (mg) 1/2 tab daily as needed for fluid retention. During a review of Patient 1's clinical record indicated on evidence of a physician's order for the Furosemide 20 milligrams (mg) 1/2 tab medication in which the patient was regularly taking. On 3/26/22, at 11:30 a.m., during an interview with Patient 2, she stated the Furosemide 20 mg medication was discontinued over 6 months now and she was not taking it anymore. On 3/27/22, at 10 a.m., during an interview with the DPCS (director of patient care services), she stated that LVN 2 should have been checking all the patient's medications during her visits. View ResourcesQIES Technical Support Office Known Issues Validation Utility Tool System Requirements Medicare Get HelpHelp Hours:Monday - Friday | 8am - 8pm ET By Phone:(800) 339-9313 By Email:iQIES@cms.hhs.gov Stay Connected

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to follow the written plan of care established by the physician that included left arterial ulcer wound assessments for one of 7 patients (3). This deficient practice had the potential in the delay of healthcare response, treatment, and intervention that could result to complications to an already compromised patient's health status. A review of Patient 3's clinical record indicated a start of care (SOC) of 9/2/2021, with diagnoses which included atherosclerosis (thickening or hardening of arteries) native arteries of left leg with ulceration on other part of foot. The Plan of Care (POC) for the certification period 3/1/2022 to 4/29/2022, included an order for Skilled Nurse (SN) frequency of daily for 21 days, three times a week for five weeks. SN was to continue doing skin assessment and observation and to provide wound care to left medial hallux (inner digit of toe) arterial ulcer for two sites ( #1 left big toe nail/bed skin exposed and #2 left medial hallux top side), to cleanse with wound cleanser, pat dry, apply SSD cream, cover with dressing and secure with tape every two days. A review of Patient 3’s Skilled Nursing Visit Notes dated 3/12, 3/13, 3/17 and 3/19/2022, did not indicate a documented evidence that the 2 sites of Patient 3’s left medial hallux arterial ulcer times two sites were assessed during the skilled nursing visits. During an interview with the Director of Patient Care Services (DPCS) on 3/27/2022, at 12 p.m., she stated she cannot provide the documented evidence the left medial hallux arterial ulcer was assessed that included measurements from dates 3/12, 3/13, 3/17 and 3/19/2022. A review of the agency’s undated policy titled “Wound Assessment and Documentation” indicated to assess the wound location and its size; measure the length, width, and depth.

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 agency failed to: a. Administer drugs and treatments as ordered by the physician for one of 7 patients (Patient 3). b. Failed to provide wound care treatment for Patient 3 as per physician's order. This deficient practice had potential to cause delayed wound healing and worsening of the pressure ulcer of the affected patient. A review of Patient 3's clinical record indicated a start of care (SOC) of 9/2/2021, with diagnoses which included atherosclerosis (thickening and hardening of the arteries) native arteries of left leg with ulceration on other part of foot. The plan of care (POC) for the certification period from 3/1/2022 to 4/29/2022, included an order for Skilled Nurse (SN) daily for 21 days, three times a week for five weeks. SN was to continue doing skin assessment and observation and to provide wound care to left medial hallux (inner toe digits) arterial ulcer for two sites ( #1 left big toe nail/bed skin exposed and #2 left medial hallux top side) , to cleanse with wound cleanser, pat dry, apply SSD cream, cover with dressing and secure with tape every two days. A review of Patient 3’s Skilled Nursing Visit Notes dated 3/12, 3/13, 3/17 and 3/19/2022, did not indicate a documented evidence the visiting nurse provided wound care treatment every visits. On 3/27/2022, at 11:30 a.m., , during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she provided wound care treatment and should have documented it in the nursing notes. On 3/27/2022, at 12:15 p.m., during an interview with the DPCS (director of patient care services), she stated LVN 1 should document every treatment they provide to the patient in their nursing notes.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to screen the visitors for signs and symptoms of COVID-19 (an acute serious respiratory illness) and failed to ensure nursing staff were fitted to wear an N-95 mask (a specialized mask used to reduce exposure to virus particles) while providing care to patients. This failure had the potential to spread COVID-19 virus to other staff and patients. During an observation on 3/25/2022 at 2:00 p.m., upon entrance to the HHA, there was no screening for COVID-19 signs and symptoms, including temperature checking. During an interview on 3/27/2022 at 11:38 a.m., the Director of Patient Care Services (DPCS) stated patient care staff had not been fit tested to wear an N95 mask. The DPCS stated fit testing is important because it ensures the mask fits well and this will control the spread of virus or infection. During an interview on 3/27/2022 at 11:48 a.m., the Director of Patient Care Services (DPCS) stated the agency screens employees and visitors for COVID 19 symptoms, but the information is not documented. The DPCS also stated temperatures are not checked for employees and visitors entering the HHA. During a review of the infection control policy on 3/27/2022 at 11:50 a.m., the HHA did not have a policy for COVID-19 screening procedures for staff and visitors. A review of the HHA’s undated policy and procedure titled, “CNHHA-Covid 19”, indicated “Surgical mask or higher-level respirators (e.g., N95’s…with good fit are highly recommended”. A review of the HHA’s undated policy and procedure titled, “Infection Control Procedures”, indicated “It is the policy of California Nurses Home Health Services to protect the clients and the health care workers from potential spread of infection.”