Every finding on record at Nurse at Home

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 2/10/25 through 2/12/25, the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 2/10/25 through 2/12/25. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 55 patients at the time of the survey.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on home visit observation and admission folder review, the agency failed to provide agency patients with the Administrator name, business address and business phone number. The agency failed to provide this information for 2 of 3 sampled patients with home visits (Patients #2 and #3). Failure to provide the Administrator name and contact information left the patients without the needed information to contact the agency Administrator with any concerns that may have occurred. 2. Patient #3 had a start of care date of 2/4/25. Home Observation and clinical record revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25, included a primary diagnosis of chronic leukemia and heart failure and interim physician orders for skilled nursing, physical therapy and home health aide services. b. During a home observation visit on 2/11/25 at 9:30 AM with Staff F, Registered Nurse (RN), the surveyor reviewed the admission folder in the patient home. The folder failed to provide the agency Administrator name and contact information. The agency failed to provide the agency Administrator name and contact information for the patient. Findings include: 1.Patient #2 had a start of care date of 1/21/25. Clinical record review revealed a Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nursing, physical therapy and occupational therapy services. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (Certified Occupational Therapy Assistant), the surveyor reviewed the admission folder in the patient home. The folder failed to provide the agency Administrator name and contact information. The agency failed to provide the agency Administrator name and contact information for the patient.

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 observations, agency staff interview, patient interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment and failed to identify patient specific medication issues for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5 and #7). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Medication List and Monitoring, dated 4/13/22, the agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. The Registered Nurse will monitor medications for potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Agency nursing staff will assess on an ongoing basis the patient’s response to medication and the patient/caregiver compliance with the medication regimen. 1.Patient #3 had a start of care date of 2/4/25. Clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified the patient as having primary diagnosis of chromic leukemia and heart failure and physician orders for medications and treatments, with skilled nurse, physical and occupational therapy, and home health aide services. b. The start of care comprehensive assessment, dated 2/4/25, Staff F, Registered Nurse (RN), included documentation of drug interactions, side effects; but failed to identify duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 2. Patient #4 had a start of care date of 1/8/25. Clinical record review revealed: a. The POC, dated 1/8/25 to 3/8/25, identified the patient as having a diagnosis of hypertension and heart failure, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 1/8/25, Staff F, RN, included documentation of drug interactions but failed to identify; side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 3. Patient #5 had a start of care date of 08/22/24. Clinical record review revealed: a. The POC, dated 08/22/24 to 10/20/24, identified the patient as having a diagnosis of type 2 diabetes and Parkinson's, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 8/22/24, Staff G, RN , included documentation of drug interactions and side effects, but failed to identify, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 4. Patient #1 had a start of care date of 1/1/21. Clinical record review revealed: a. Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing and home health aide services and medications. b. Recertification comprehensive assessments, dated 8/19/24, 10/21/24 and 12/17/24, included documentation of drug interactions, side effects and duplicate medications; but failed to identify ineffective drug therapy and noncompliance with medications. The RN (registered nurse) failed to identify the required elements of the drug regimen review at the recertification comprehensive assessments. 5. Patient #2 had a start of care date of 1/21/25. Clinical record review revealed: a. Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy and occupational therapy services and medications. b. Start of Care comprehensive assessment, dated 1/21/25, included documentation of drug interactions, but failed to identify side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start pf care comprehensive assessment. 6. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services and medications. b. Start of Care comprehensive assessment, dated 8/9/24, failed to include documentation a drug regimen review had been completed. During an interview on 2/12/25 at 2:38 PM, Clinical Manager reported she had reviewed the clinical record and the comprehensive assessment included documentation under the Medications section, medications reconciled and the question labeled M2001-Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?, was marked as No, No issues found during review. She reported this serves as the drug regimen review and when this question is marked No, the nurse is not able to add any additional documentation. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. The surveyor reviewed the above stated findings with Administrator and Clinical Manager. Findings include: According to the agency policy titled Medication List and Monitoring, dated 4/13/22, the agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. The Registered Nurse will monitor medications for potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Agency nursing staff will assess on an ongoing basis the patient’s response to medication and the patient/caregiver compliance with the medication regimen. 1.Patient #3 had a start of care date of 2/4/25. Clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified the patient as having primary diagnosis of chromic leukemia and heart failure and physician orders for medications and treatments, with skilled nurse, physical and occupational therapy, and home health aide services. b. The start of care comprehensive assessment, dated 2/4/25, Staff F, Registered Nurse (RN), included documentation of drug interactions, side effects; but failed to identify duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 2. Patient #4 had a start of care date of 1/8/25. Clinical record review revealed: a. The POC, dated 1/8/25 to 3/8/25, identified the patient as having a diagnosis of hypertension and heart failure, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 1/8/25, Staff F, RN, included documentation of drug interactions but failed to identify; side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 3. Patient #5 had a start of care date of 08/22/24. Clinical record review revealed: a. The POC, dated 08/22/24 to 10/20/24, identified the patient as having a diagnosis of type 2 diabetes and Parkinson's, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 8/22/24, Staff G, RN , included documentation of drug interactions and side effects, but failed to identify, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 4. Patient #1 had a start of care date of 1/1/21. Clinical record review revealed: a. Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing and home health aide services and medications. b. Recertification comprehensive assessments, dated 8/19/24, 10/21/24 and 12/17/24, included documentation of drug interactions, side effects and duplicate medications; but failed to identify ineffective drug therapy and noncompliance with medications. The RN (registered nurse) failed to identify the required elements of the drug regimen review at the recertification comprehensive assessments. 5. Patient #2 had a start of care date of 1/21/25. Clinical record review revealed: a. Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy and occupational therapy services and medications. b. Start of Care comprehensive assessment, dated 1/21/25, included documentation of drug interactions, but failed to identify side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start pf care comprehensive assessment. 6. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services and medications. b. Start of Care comprehensive assessment, dated 8/9/24, failed to include documentation a drug regimen review had been completed. During an interview on 2/12/25 at 2:38 PM, Clinical Manager reported she had reviewed the clinical record and the comprehensive assessment included documentation under the Medications section, medications reconciled and the question labeled M2001-Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?, was marked as No, No issues found during review. She reported this serves as the drug regimen review and when this question is marked No, the nurse is not able to add any additional documentation. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. The surveyor reviewed the above stated findings with Administrator and Clinical Manager.

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care or notify the physician of missed visits for 2 of 3 sampled patients with missed visits. (Patients #1 and #7) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings: According to the agency policy, titled Plan of Care, dated 4/13/22, modifications to the care plan are indicted by changes in visit frequencies. These are documented on discipline progress notes or a physician verbal order. Verbal orders will be signed and dated by the physician. During an interview on 2/11/25 at 3:54 PM, Clinical Manager reported the missed visit documentation is faxed to the physician and would be in the fax log in the electronic medical record. 1.Patient #1 had a start of care date of 1/1/21. Clinical record review revealed: a. Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nurse and home health aide services. b. Missed visit documentation, dated 1/3/25, included documentation patient refused the aide visit and physician was not notified. c. Missed visit documentation, dated 1/24/25, included documentation no answer to phone call for aide visit and physician not notified. Agency failed to notify the physician of missed aide visits. 2. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus and orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Missed visit documentation, dated 8/12/24, 8/23/24, 9/10/24, and 9/13/24, included documentation patient refused the aide visit and physician was not notified c. Missed visit documentation, dated 8/19/24, included documentation of a missed aide visit and physician was not notified. Agency failed to notify the physician of missed aide visits. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager.

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 home observation visits, patient/staff interviews, clinical record review and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including the functional limitations, nutritional requirements, safety measures to protect against injury, and all supplies/equipment used by the patient for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5, and #6). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to nor receive services, supplies and or treatments according to assessed needs and physician orders. 5. Patient #1 had a start of care date of 1/1/21. Clinical record review revealed the Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus and grab bars, tub/shower bench, walker, wheelchair, nebulizer as equipment and supplies the patient was using. During a home visit observation, on 2/10/25 at 1:20 PM, with Staff D, RN (registered nurse), the surveyor observed the patient siting in an electric lift chair, with 2 urinals on the floor next to the chair, a C-pap (continuous positive air pressure) mask and machine on the floor on the other side of the chair, a reacher on the cough, an electric power chair in the living room, a wheelchair cushion in the manual wheelchair and a medication planner. The patient reported using the electric power chair when leaving the home. The surveyor observed the patient using the reacher to pick up an item from the cough and hand to Staff D prior to Staff D filling the medication planner. The electric lift chair, urinal, C-pap masks and machine, reacher, electric power chair, wheelchair cushion and medication planner, failed to be included on the Plan of Care as equipment used by the patient. The Plan of Care failed to identify accurate equipment and supplies used by the patient. 6. Patient #2 had a start of care date of 1/21/25. Clinical record review revealed the Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for ketorolac ophthalmic solution and prednisolone acetate ophthalmic suspension, and grab bars, tub/shower bench, walker, wheelchair as equipment and supplies the patient was using. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (certified occupational therapy assistant), the patient reported having a reacher that was used to assist with laundry and they did not have ketorolac ophthalmic solution and/or prednisolone acetate ophthalmic suspension and has never used these medications. The reacher failed to be included on the Plan of Care as equipment used by the patient and the ophthalmic medications were inaccurately added to the Plan of Care as medications used by the patient. The Plan of Care failed to identify accurate equipment, supplies and medications used by the patient. The surveyor reviewed the above stated findings with Administrator and Clinical Manager. Findings include: According to the policy titled Plan of Care, dated 4/13/22, the Plan of Care (POC) is developed in consultation with the staff, client, physician, and other providers involved in the clients care. The POC includes: diagnosis, allergies, homebound status if required, goals and outcomes to be achieved, mental status, functional limitations, activities permitted, safety measures to protect against injury, nutritional requirements, medications/treatments, procedures/treatments including amount, frequency and duration, supplies and equipment required, instructions and discharge plan, frequency/duration of visits, prognosis, rehabilitation potential and any other appropriate items such as precautions and contraindications. 1.Patient #3 had a start of care date of 2/4/25. Home observation and clinical record review revealed the following: a. The POC, dated 2/4/25 to 4/4/25, identified the patient had a primary diagnosis of chronic leukemia. The POC identified the following durable medical equipment (DME) used by the patient: grab bars, tub/shower bench, nebulizer, walker, toilet rails. b. During a home observation visit on 2/11/25 at 9 AM with Staff F, Registered Nurse (RN), the surveyor identified the following DME used by the patient: medication planner, a lift chair, and testing supplies for PT/INR (test that determines how long it takes for the blood to clot). During the same observation visit, patient stated the daughter had been assisting with the PT/INR testing routinely in the home. The agency failed to include all of the DME utilized by the patient on the POC. 2. Patient #4 had a start of care date of 1/8/25. Clinical record review revealed the following: a. The POC, dated 1/8/25 to 3/8/25, identified the patient had a primary diagnosis of hypertension and heart failure. The POC identified the only DME item used by the patient was a walker. b. The initial comprehensive assessment dated 1/8/2025, completed by Staff F, RN, included physicians orders for the skilled nurse to teach patient how to use oxygen safely in the home. c. The skilled nurse visit note, dated 1/13/25, completed by Staff F, RN, indicated the skilled nurse was filling a medication planner to assist the patient to take medications at appropriate times with correct dose. The agency failed to include all of the DME utilized by the patient on the POC. 3. Patient #5 had a start of care date of 11/10/22. Clinical record review revealed the following: a. The POC, dated 1/4/24 to 3/3/24, identified the patient had a primary diagnosis of type 2 diabetes with hyperglycemia (elevated blood sugars). The POC identified the DME being used by the patient as: grab bars, walker, elevated toilet seat, bedside commode, tub/shower bench and a wheelchair. b. The Initial comprehensive assessment dated 8/23/24, completed by Staff F, RN, identified a medication planner would be used to set up the patients medications on a routine basis. The agency failed to include all of the DME utilized by the patient on the POC. 4. Patient #6 had a start of care date of 7/1/24. Clinical record review revealed the following: a. The POC, dated 7/1/24 to 8/29/24, identified the patient had a primary diagnosis of left arm fracture and type 2 diabetes. The POC failed to address the following areas : mental/cognitive status, functional limitations, safety interventions to prevent injury, nutritional requirements, and activities either permitted or restricted. The agency failed to develop an accurate and completed POC at the start of care.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on home observations, staff and agency interviews, clinical record review and policy review, the agency failed to maintain a working Plan of Care for patients and update the working Plan of Cre with any new verbal/interim physician orders for 2 of 4 sampled patients (Patient #3 and #7) with interim physician orders Failure to update the Plan of Care increase the potential for medication errors in administration or in accurate provision and follow through with care. 2. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus and orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Interim physician order, dated 8/17/24, with an effective date of 8/17/24, for skilled nurse to perform wound care to abdominal wound daily. The clinical record lacked documentation of a Plan of Care update for the wound care to be provided daily. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. Findings include: According to agency policy titled Plan of Care, dated 4/13/22, identify modifications to the care plan are indicated by reassessments, patient condition , patient needs, changes in orders, and/or achievement of identified goals, and/or changes n visit sequencies. 1.Patient #3 had a start of care date of 2/4/25. Clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified a diagnosis of chronic leukemia and heart failure, with physician orders for medications and treatments with orders for skilled nurse, physical and occupational therapy, and home health aide services. The POC indicated the care giver would be monitoring and performing the PT/INR testing(a test that determines how fast the blood is clotting) on a weekly basis. b. An interim physician order, dated 2/4/25, directed the Registered Nurse (RN) to perform testing for PT/INR weekly with skilled nursing visit and to call the results into the coumadin clinic for dosing instructions. The agency failed to ensure the POC was updated to include all patient care orders.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation and admission folder review, the agency failed to provide agency patients with visit schedule, including frequency of visit by agency personnel and personnel acting on behalf of the agency. The agency failed to provide this information for 1 of 2 sampled patients with home visits with admit folders in the home (Patient #2). Failure to provide the visit schedule left the patients at risk of not receiving the appropriate services as ordered. Findings include: Patient #2 had a start of care date of 1/21/25. Clinical record review revealed a Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nursing, physical therapy and occupational therapy services. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (Certified Occupational Therapy Assistant), the surveyor reviewed the admission folder in the patient home. The folder failed to include a visit schedule. The agency failed to provide the patient and caregiver with a visit schedule. The findings were reviewed with Administrator and Clinical Manager.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on home visit observation and admission folder review, the agency failed to provide agency patients with written information on any treatments to be administered by agency personnel acting on behalf of the agency, including therapy services. The agency failed to provide this information for 1 of 2 sampled patients with home visits and therapy services (Patient #2). Failure to provide the patient with written information on treatments administered by the agency put the patient at risk for not receiving the ordered treatments including therapy services. Findings include: Patient #2 had a start of care date of 1/21/25. Clinical record review revealed a Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nursing, physical therapy and occupational therapy services. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (Certified Occupational Therapy Assistant), the surveyor reviewed the admission folder in the patient home. The folder failed to identify any treatments to be administered by agency personnel and personnel acting on behalf of the agency, including therapy services. The agency failed to ensure the patient had written instructions outlining the treatments and services being provided. The findings were reviewed with Administrator and Clinical Manager.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on home observations, staff interviews, clinical record review and policy review, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice for 2 of 3 sampled patients (Patient #1 and #3) with home observation visits. Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infections. 2. Patient #1 had a start of care dated of 1/1/21. The surveyor accompanied Staff D, Registered Nurse (RN), to a home visit on 2/10/25 at 1:20 PM. Staff D while applying Vaseline to patient’s lower legs, removed gloves, removed stethoscope from around her neck and placed in nursing bag, pulled hair back into a pony tail, reapplied gloves, and continued to apply Vaseline to patient’s lower legs. Staff D failed to complete hand hygiene after removing gloves and before putting on new gloves and to clean stethoscope prior to returning it to the nursing bag. The agency failed to ensure infection control standards were followed during patient care. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. Findings include: According to the agency policy titled Bag Technique, dated 4/13/22, the nursing bag is placed on a clean surface in the home and following hand hygiene the supplies and or equipment needed for the visit are removed from the bag. When the visit is completed, reusable equipment is cleaned using alcohol disinfectant wipe and or soap/water as appropriate and placed on a clean surface, hands are washed and equipment is returned to the bag. 1.Patient #3 had a start of care date of 2/4/25. Home observation and clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified the patient as having primary diagnosis of chromic leukemia and heart failure and physician orders for medications and treatments, with skilled nurse, physical and occupational therapy, and home health aide services. b. During a home observation visit on 2/11/25 at 9:15 AM with Staff F, Registered Nurse (RN), the surveyor observed the RN returning the vital sign equipment back inside her bag without disinfecting the items first. The agency failed to perform bag technique according to agency policy and in accordance with accepted infection control standards of practice

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to provide wound care as ordered by a physician for 1 of 1 sampled patients with wounds (Patient #7). Failure to ensure staff obtain physician orders for administration of services provided by agency staff, including wound care, placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care, dated 4/13/22, modifications to the care plan are indicated by reassessments, patient condition/needs, changes in orders are documented on discipline progress notes or physician verbal orders. Verbal orders will be signed and dated by the physician. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus and orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Interim physician order, dated 8/15/24, included documentation skilled nurse to provide wound care 5 days per week, per physician order, until wound closed. The order failed to identify what specific wound care should be provided. c. Skilled nursing visit, dated 8/16/24, included documentation a surgical wound central abdomen, measured 0.5 centimeters (cm) by 0.1 cm by 1 cm with tunneling of 3 cm at 12:00. Wound care performed using aseptic technique per physician order. d. Interim physician order, dated 8/17/24, with an effective date of 8/17/24, included documentation skilled nurse to perform wound care to abdominal wound, remove packing, cleanse wound, repack with quarter inch packing and cover with 4x4 gauze and secured with tape, using aseptic technique. Wound care daily. During an interview on 2/12/24 at 2:38 PM, Clinical Manager reported the nurse entered the incorrect start and effective date on the order, it should have been 8/15/24 instead of 8/17/24. Skilled nurse provided wound care without a physician order. The findings were reviewed with the Administrator and Clinical Manager.

The recertification survey, conducted from 3/21/2022 through 3/30/2022, found the agency operating out of compliance with the following standard level deficiencies related to Appendix Z Establishment of Emergency Preparedness.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan with associated policies and agency staff interview, the agency failed to complete a full scale exercise that is community based every 2 years or activate the emergency plan due to an actual or manmade emergency/disaster. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for inadequate response due to a lack of trained/prepared staff to assist in the event of an emergency. Findings include: Review of the agency's emergency preparedness plan and associated policies revealed the following: The agency's emergency preparedness binder included a tabletop exercise with analysis, dated 5/31/2019; a table top exercise with analysis, dated 3/19/2020; mock disaster drills for fire/tornado/evacuation, dated 1/29/2021 and 6/29/2021. The binder lacked documentation of a full-scale community based exercise or activation of the agency's emergency plan in response to an actual emergency/disaster between 2018 and 2021. The mock disaster drills lacked a follow up analysis to determine the effectiveness of the emergency plan after both the 1/29/2021 and the 6/29/2021 drills. During agency staff interview on 3/29/22 at 1:02 PM, the Clinical Manager reported a full-scale community based testing had not been completed. The Clinical Manager verified the agency had not activated its emergency plan due to an actual emergency between 2018 and 2021. The agency failed to perform either a full-scale community based exercise every 2 years. The agency failed to perform an analysis of its mock disaster drills. The above stated findings were reviewed with the Administrator and the Clinical Manager. The agency provided no further information prior to the end of the survey.

The Department of Inspections and Appeals conducted a recertification survey in conjunction with two complaint investigations for complaint #62259 and complaint #62157 related to the Conditions of Participation 42 CFR 484.50 Patient Rights, 42 CFR 484.80 Home Health Aide Services, and 42 CFR 484.110 Clinical Records from 3/21/22 through 3/30/22. Complaint #62259 and #62157 were substantiated. The survey found the agency operating out of compliance with the following condition level deficiencies: 1) Condition of Participation 42 CFR 484.50 Patient Rights (G406, G478, G484, and G486) 2) Condition of Participation 42 CFR 484.60 Care planning, Coordination, Quality of Care (G5570, G572, G574) 3.) Condition of Participation 42 CFR 484.80 Home Health Aide Services (G750, G768, G798, and G800) 4.) Condition of Participation 42 CFR 484.100 Compliance with Federal, State, Local Law (G860) and 5.) Condition of Participation 42 CFR 484.110 Clinical Records (G1008, G1024 and G1026). The survey also found the agency operating out of compliance with multiple standard level deficiencies. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 3/30/22 and ending on 3/30/24. The agency reported a current census of 139 patients at the time of the survey.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on review of the agency's complaint file, agency policy review, personnel file review, clinical record review, agency staff interview and patient/caregiver interview, the agency was found operating out of compliance with this Condition of Participation for the following reasons: 1) the agency failed to investigate complaints received (G478); 2) the agency failed to document the resolution to all complaints received (G484); and 3) the agency failed to take further action to prevent reoccurrence of complaints (G486). The systemic practice resulted in the failure to ensure the organization framework of the agency promoted and protected the rights of the agency's 139 patients.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on review of the agency's complaint log, agency policy review, personnel file review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to investigate complaints made by the patient, patient's representative, caregivers and family members for 1 of 1 sampled patients with complaints (Patient #7). The agency reported one complaint received since the last survey. Failure to investigate complaints increased the risk of inappropriate or inadequate care provision and prevented the patient/caregiver/representative/family member from exercising the right to voice grievances and have the grievances resolved. Findings include: According to the undated agency policy, titled Resolution of Patient Conflicts, Grievances or Complaints, the agency will receive, document, address and resolve conflicts that involve complaints made by the patient, a patient's family or guardian, or a patient's health care provider. The agency will investigate complaints made regarding treatment or care that was furnished by the agency; treatment or care that the agency failed to furnish; lack of respect for the patient's property by anyone furnishing services on behalf of the agency. The agency will complete the investigation and documentation within 30 days after receipt of the complaint unless the agency had and documents reasonable cause for delay; the agency will involve the patient/caregiver/and/or patient's physician as appropriate to reach a resolution. All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff. Resolution/outcome will be communicated to the complainant. All abuse, neglect or exploitation reports will follow agency policy on Abuse, Neglect and Exploitation. According to the undated agency policy, titled Abuse/ Neglect Allegations, all cases of suspected abuse/neglect/exploitation as defined in the policy, whether or not an actual injury has occurred, will be reported and investigated promptly in compliance with state law and regulation. Elder exploitation is defined as the act or process of taking advantage of an elderly person by another person or caregiver whether for monetary, personal or other benefit, gain or profit. Documentation should be complete and thorough, including every step of the investigation. Reporting will be based on the results of the investigation and mandated reporting requirements. Review of the agency's complaint log revealed only one complaint made since the last survey. The complaint log documented the following: Patient #7's family member came to the office to report a former employee (Staff J, Home Health Aide) owed money. The family member was requesting information about the employee, including name, phone number and address. The Administrator reported she was unable to share the information with the family member so the family member made the choice to file a small claims report on the previous staff member. "Follow up: Administrator called former employee (Staff J, Home Health Aide) and left a message to call x3 with no return call." During patient caregiver interview on 3/21/2022 at 4:45 PM, the sibling of Patient #7 reported residing with the patient for the past 10 years. Patient #7 received services from Nurse At Home on 2 occasions. The first episode of care ended on 10/1/2021 as another family member planned to assist the sibling with the patient's care. The new arrangement did not work out well, so the patient was readmitted to Nurse At Home on 10/25/2021 and received nurse and home health aide services until a hospitalization in December 2021 at which time the patient was discharged from the agency services. During the first episode of care, sometime in September 2021, Staff J, Home Health Aide, was sitting on the patient's living room floor- upset- reporting having no money to buy gas or food and was unable to feed children. Patient #7's sibling reported feeling sorry for her "so (Patient #7) and I talked and decided to give (Staff J) money to help. We gave (Staff J) a Walmart card with $80.00 on it that we had purchased for our gas and a $100.00 bill. We split all expenses in half so we split the cash and I am not sure who paid for the Walmart card as we take turns. We have separate bank accounts in different banks." Staff J, Home Health Aide, reported a plan to pay the money back but did not." "I didn't want to get the aide in trouble at work so I allowed the aide to tell Nurse At Home of the loan. That never occurred. When the patient started back with the agency, the sibling (who is the primary caregiver of the Patient #7) reported requesting Staff J, home health aide, not be allowed back in the home. The patient's sibling reported telling agency staff about the situation after being readmitted. Believed told the primary registered nurse (RN) and the new home health aide. "I eventually went to the Nurse At Home office to get the last name and contact information so I could try to get the money back by filing in small claims. They said they couldn't give me that information." During agency staff interview on 3/28/2022 at 1:35 PM, the Clinical Manager reported no investigation was done on the complaint made by the family member of Patient #7 as the aide no longer worked for the agency, the patient no longer received services and the family member was not upset about things after finding out the aide no longer worked for the agency. The Clinical Manager reported she was the primary RN for Patient #7 during the second episode of care admission and had never had knowledge of the exchange of money between the patient/caregiver and Staff J, Home Health Aide, until 2/4/2022 when the patient's sibling came to the office. During agency staff interview on 3/28/2022 at 9:00 PM, Staff M, Home Health Aide, reported providing care to Patient #7. Staff M reported the patient's sibling often talked about " (Staff J) giving a sob story about not having money for bills- she didn't outright ask for the money but (Patient #7 and (sibling) gave her money then, after many attempts to collect, the aide quit taking calls" to collect. Staff M, Home Health Aide reported she never reported this to the office as she felt it was not her business. During agency staff interview on 3/29/2022 at 11:32 AM, Staff N, previous Office Manager, reported she worked for Nurse At Home until 1/17/2022 at which time she resigned. Staff N reported receiving a call shortly before resigning from Patient #7's sibling. The sibling reported "(Patient #7) and (the sibling) gave some cash and a Walmart card to (Staff J, Home Health Aide), as Staff J cried about having no money and Staff J didn't repay it." By this time, Staff J, Home Health Aide, no longer worked for Nurse At Home so Staff N reported it immediately to the Administrator. Staff N reported she is unsure if the Administrator ever followed up with Patient #7's sibling. Personnel file review revealed: Staff J, Home Health Aide, had a hire date of 5/20/2020. The personnel file lacked any documentation of resignation or termination. The file included a Conflict of Interest Annual Disclosure Statement, dated as signed by Staff J on 5/20/2020. The Disclosure documented Nurse At Home employees and representatives will not accept nor allow any family member to accept money, gifts or hospitality of other that nominal value, loans or any other preferential treatment from any supplier, customer, contractor or competitor of the agency. During staff interview on 3/29/2022 at 10:38 AM, Staff J, Home Health Aide, reported she had worked with Patient #7 during the first episode of care. Staff J, Home Health Aide, denied receiving a Walmart card with money on it and denied being loaned any money from Patient #7 or the patient's representative. Denies being contacted by Patient #7 or the patient's representative to collect any money. Reports left employment "just was not a good place to work." On 3/28/2022 at 3:00 PM, the Clinical Manager presented a computer screen print documenting on 11/2/2021 Staff J, Home Health Aide, called in with an emergency. Later in the day, a licensed practical nurse employed by Nurse At Home saw the aide working at a facility in a nearby town. The aide reported she no longer worked for Nurse At Home. All attempts to contact Staff J, Home Health Aide, were unsuccessful. The agency completed no investigation into Patient #7's sibling's concerns. The only attempt at an investigation was to call Staff J, Home Health Aide, three times and leave messages to return the call unsuccessfully. The agency did not follow it's own policies requiring a thorough investigation to determine the facts of the money exchange or to determine other's with knowledge to interview which hindered identification of potential exploitation as identified in the agency's policy and agency responsibility for staff involved. The above stated findings were reviewed with the Clinical Manager. On 3/29/2022 at 11:20 AM, the Clinical Manager presented the surveyor with an investigation into the complaint facts, completed by the Clinical Manager on 3/28/2022.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on review of the agency's complaint log, agency policy review and agency staff interview, the agency failed to document a resolution to all complaints received for 1 of 1 sampled patients with a complaint (Patient #7). The agency reported only one complaint received since the last survey. Failure to investigate/resolve complaints increased the risk of inappropriate or inadequate care provision and prevented the patient/caregiver/representative/family member from exercising the right to voice grievances and have the grievances resolved. Findings include: According to the undated agency policy, titled Resolution of Patient Conflicts, Grievances or Complaints, the agency will receive, document, address and resolve conflicts that involve complaints made by the patient, a patient's family or guardian, or a patient's health care provider. The agency will investigate complaints made regarding treatment or care that was furnished by the agency; treatment or care that the agency failed to furnish; lack of respect for the patient's property by anyone furnishing services on behalf of the agency. The agency will complete the investigation and documentation within 30 days after receipt of the complaint unless the agency had and documents reasonable cause for delay; the agency will involve the patient/caregiver/and/or patient's physician as appropriate to reach a resolution. All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff. Resolution/outcome will be communicated to the complainant. All abuse, neglect or exploitation reports will follow agency policy on Abuse, Neglect and Exploitation. Review of the agency's complaint log revealed only one complaint made since the last survey. The complaint log documented the following: Patient #7's family member came to the office to report a former employee (Staff J, Home Health Aide) owed money. The family member was requesting information about the employee, including name, phone number and address. The Administrator reported she was unable to share the information with the family member so the family member made the choice to file a small claims report on the previous staff member. "Follow up: Administrator called former employee (Staff J, Home Health Aide) and left a message to call x3 with no return call." (See G478 for additional interviews and facts about the complaint) During agency staff interview on 3/28/2022 at 1:35 PM, the Clinical Manager reported no investigation was done on the complaint made by the family member of Patient #7 as the aide no longer worked for the agency, the patient no longer received services and the family member was not upset about things after finding out the aide no longer worked for the agency. The agency completed no investigation into Patient #7's concerns. The only attempt at an investigation was to call Staff J, Home Health Aide, three times and leave messages to return the call unsuccessfully. The agency did not follow it's own policies to determine a resolution to the complaint and document the resolution as required by agency policy. The above stated findings were reviewed with the Clinical Manager. On 3/29/2022 at 11:20 AM, the Clinical Manager presented the surveyor with an investigation into the complaint facts, completed by the Clinical Manager on 3/28/2022. The Clinical Manager documented the complaint resolved as she determined the money exchange was a personal transaction and did not involve the agency.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on review of the agency's complaint log, agency policy review and agency staff interview, the agency failed to take further action related to a complaint registered with the agency to prevent reoccurrence in the future for 1 of 1 sampled patients with a complaint (Patient #7). The agency reported only one complaint received since the last survey. Failure to investigate/resolve complaints increased the risk of inappropriate or inadequate care provision and prevented the patient/caregiver/representative/family member from exercising the right to voice grievances, have the grievances resolved and make changes to prevent reoccurrence in the future. Findings include: According to the undated agency policy, titled Resolution of Patient Conflicts, Grievances or Complaints, the agency will receive, document, address and resolve conflicts that involve complaints made by the patient, a patient's family or guardian, or a patient's health care provider. The agency will investigate complaints made regarding treatment or care that was furnished by the agency; treatment or care that the agency failed to furnish; lack of respect for the patient's property by anyone furnishing services on behalf of the agency. The agency will complete the investigation and documentation within 30 days after receipt of the complaint unless the agency had and documents reasonable cause for delay; the agency will involve the patient/caregiver/and/or patient's physician as appropriate to reach a resolution. All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff. Resolution/outcome will be communicated to the complainant. All abuse, neglect or exploitation reports will follow agency policy on Abuse, Neglect and Exploitation. Review of the agency's complaint log revealed only one complaint made since the last survey. The complaint log documented the following: Patient #7's family member came to the office to report a former employee (Staff J, Home Health Aide) owed money. The family member was requesting information about the employee, including name, phone number and address. The Administrator reported she was unable to share the information with the family member so the family member made the choice to file a small claims report on the previous staff member. "Follow up: Administrator called former employee (Staff J, Home Health Aide) and left a message to call x3 with no return call." (See G478 and G484 for additional interviews and facts about the complaint) During agency staff interview on 3/28/2022 at 1:35 PM, the Clinical Manager reported no investigation was done on the complaint made by the family member of Patient #7 as the aide no longer worked for the agency, the patient no longer received services and the family member was not upset about things after finding out the aide no longer worked for the agency. The agency completed no investigation into Patient #7's concerns. The only attempt at an investigation was to call Staff J, Home Health Aide, three times and leave messages to return the call unsuccessfully. The agency did not follow it's own policies to determine a resolution to the complaint and document the resolution as required by agency policy. The agency did not take action to prevent potential violations while the complaint was being investigated to prevent further reoccurrences. The above stated findings were reviewed with the Clinical Manager. On 3/29/2022 at 11:20 AM, the Clinical Manager presented the surveyor with an investigation into the complaint facts, completed by the Clinical Manager on 3/28/2022. The Clinical Manager documented a plan to prevent reoccurrence of the complaint issues to protect patients in the future. The Clinical Manager documented a plan to hold, within 30 days, a mandatory meeting covering the varying types of Dependent Adult Abuse, how to identify, and the requirements of reporting to the Clinical Manager as well as how to report to the State of Iowa. Nurse At Home will review it's current policy regarding Dependent Adult Abuse and reporting requirements to ensure the policy reflects the most up to date information provided by the State of Iowa. Nurse At Home will also update and provide more than one person within management that reports of Dependent Adult Abuse can be made to and the time frame those reports should be made in.

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 agency policy review, clinical record review, and staff interview, the agency failed to accurately complete a drug regimen review (DRR), including completion of all required components and identification of any findings within the required time frames as part of the comprehensive assessment for 9 of 9 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8 and #11). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. 7. Patient #6 had a start of care date of 6/13/2019. Clinical record review revealed the following: a. The Plans of Care, dated 8/1/2021 to 9/29/2021 and 9/30/2021 to 11/28/2021, documented the patient took spironlactone, isosorbide mononitrate, metoprolol and furosemide, all diuretics/medications taken to lower the blood pressure; Invokana, glimiperide and Xultophy, all antidiabetic medications; low dose aspirin and Plavix, both blood thinners; and pantoprazole and ranitidine, both antiulcer medications. The update to the comprehensive assessment at the time of recertification, dated 9/29/2021, included an assessment of the patient's medications (drug regimen review). The drug regimen review documented the RN identified duplication of blood thinners and dual diuretics. The RN failed to identify the patient's use of duplicate antidiabetic medications and duplicate antiulcer medications. b. The Plan of Care, dated 11/29/2021 to 1/27/2022, documented the patient took spironlactone, isosorbide mononitrate, metoprolol and furosemide, all diuretics/medications taken to lower the blood pressure; Invokana, glimiperide and Xultophy, all antidiabetic medications; low dose aspirin and Plavix, both blood thinners; and pantoprazole, sucralfate and famotidine, all antiulcer medications; Zetia and atorvastatin, both cholesterol medications. The update to the comprehensive assessment at the time of recertification, dated 11/24/2021, included an assessment of the patient's medications (drug regimen review). The drug regimen review documented the RN identified duplication of blood thinners and dual diuretics. The RN failed to identify the patient's use of duplicate antidiabetic medications, duplicate cholesterol medications and duplicate antiulcer medications. c. The Plan of Care, dated 1/28/2022 to 3/28/2022, documented the patient took spironlactone, isosorbide mononitrate, metoprolol and furosemide, all diuretics/medications taken to lower the blood pressure; Invokana, glimiperide and Xultophy, all antidiabetic medications; low dose aspirin and Plavix, both blood thinners; and pantoprazole, sucralfate, Nexium and famotidine, all antiulcer medications; Zetia and atorvastatin, both cholesterol medications. The update to the comprehensive assessment at the time of recertification, dated 1/26/2022, included an assessment of the patient's medications (drug regimen review). The drug regimen review documented the RN identified duplication of blood thinners and dual diuretics. The RN failed to identify the patient's use of duplicate antidiabetic medications, duplicate cholesterol medications and duplicate antiulcer medications. 8. Patient #7 had a start of care date of 10/9/2020 and was discharged from agency services on 10/1/2021. The patient was readmitted to services on 10/25/2021 and was discharged from agency services on 12/20/2021. Clinical record review revealed the following: a. The Plans of Care, dated 6/6/2021 to 8/4/2021 and 8/5/2021 to 10/3/2021, documented the patient took hydralazine, furosemide and metoprolol, all diuretics/medications taken to lower the blood pressure; Lantus and Humalog, both antidiabetic medications; low dose aspirin and Plavix, both blood thinners; and Miralax (polyethylene glycol with docusate sodium) and docusate sodium, both medications containing docusate sodium (a medication used to soften stool). The update to the comprehensive assessment at the time of recertification, dated 8/4/2021, and the update to the comprehensive assessment at the time of discharge, dated 10/1/2021, included an assessment of the patient's medications (drug regimen review). The drug regimen review documented the RN identified only potential medication interactions between an antibiotic and insulin. The RN failed to identify the patient's use of duplicate blood thinners, duplicate antidiabetic medications, duplicate diuretic/blood pressure medications and duplicate stool softeners. b. The Plan of Care, dated 10/25/2021 to 12/23/2021, documented the patient took hydralazine, furosemide and metoprolol, all diuretics/medications taken to lower the blood pressure; Lantus and Humalog, both antidiabetic medications; low dose aspirin and Plavix, both blood thinners; and Miralax (polyethylene glycol with docusate sodium) and docusate sodium, both medications containing docusate sodium (a medication used to soften stool). The initial comprehensive assessment at the time of readmission, dated 10/25/2021, included an assessment of the patient's medications (drug regimen review). The drug regimen review documented the RN identified only potential medication interactions between an antibiotic and insulin. The RN failed to identify the patient's use of duplicate blood thinners, duplicate antidiabetic medications, duplicate diuretic/blood pressure medications and duplicate stool softeners. 9. Patient #8 had a start of care date of 8/17/2017. Clinical record revealed the following: The Plans of Care, dated 7/27/2021 to 9/24/2021, 9/25/2021 to 11/23/2021, 11/24/2021 to 1/22/2022, and 1/23/2022 to 3/23/2022, documented the patient took Humalog and Lantus, both antidiabetic medications. a. The updates to the comprehensive assessment at the time of recertification, dated 9/24/2021, 1/21/2022 and 3/22/2022, failed to include identification of the duplicate antidiabetic medications. b. The update to the comprehensive assessment at the time of resumption of care following an acute care hospital stay, dated 11/23/2021, failed to include identification of the duplicate antidiabetic medications. The surveyors reviewed the above stated findings for Patients #1, #2, #3, #4, #5, #6, #7, #8 and #11 with the Administrator, the Clinical Manager and Staff A, Office Admin. The agency provided no additional information prior to the end of the survey. 4. Patient #1 had a start of care date of 1/18/21. The Plans of Care, dated 1/18/21 to 3/18/21, 11/14/21 to 1/12/22, 1/13/22 to 3/13/22, and 3/14/22 to 5/12/22, included orders for Memantine and Donepezil (both medications prescribed for dementia). Clinical record review revealed the following: a. The initial comprehensive assessment at start of care, dated 1/18/21, identified medications were reconciled, however, lacked documentation of completion of the required drug regimen review at the time of start of care including all required components of 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. b. The updates to the comprehensive assessment for recertification, dated 11/9/21, 1/11/22, and 3/9/22, identified medications were reconciled and included assessment of all required components. The assessment identified duplicate drug therapy, however did not identify the duplicate drug therapies identified. The clinical record lacked assessments of a complete drug regimen review with the comprehensive assessments. 5. Patient #3 had a start of care date of 8/4/18. The Plans of Care, dated 9/27/21 to 11/25/21, 11/26/21 to 1/24/22, 1/25/22 to 3/25/22, and 3/14/22 to 5/12/22, included orders for Furosemide and Spironolactone (both medications are diuretics prescribed for swelling). Clinical record review revealed the updates to the comprehensive assessment for recertification, dated 9/23/21, 11/23/21, and 1/24/22, identified medications were reconciled and included assessment of all required components. The assessment identified duplicate drug therapy as dual insulin, gastrointestinal and central nervous system medications. The assessments lacked identification of the duplicate meds prescribed as diuretics. The clinical record lacked assessments of a complete drug regimen review with the comprehensive assessments. 6. Patient #11 had a start of care date of 10/22/21 and a discharge date of 12/17/22. The Plan of Care, dated 10/22/21 to 12/20/22, included orders for Albuterol, Budesonide, Ipratropium, and Yuperli (all medications prescribed to improve breathing) and Cetirizine and Fluticasone (both medications prescribed for allergies). Clinical record review revealed the following: a. The initial comprehensive assessment at start of care, dated 10/22/21, identified medications were reconciled, however, lacked documentation of completion of the required drug regimen review at the time of start of care including all required components of 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. b. The update to the comprehensive assessment at the time of discharge, dated 12/17/21, identified medications were reconciled, however, lacked documentation of completion of the required drug regimen review at the time of start of care including all required components of 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. The clinical record lacked assessments of a complete drug regimen review with the comprehensive assessments. Findings include: According to the undated agency policy, titled Medication List and Monitoring, the agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. The Registered Nurse will monitor medications for potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. 1. Patient #2 had a start of care date of 3/25/2020. Clinical record review revealed the following: a. The Plans of Care, dated 1/14/22 to 3/14/22 and 3/15/22 to 5/13/22 included orders for duplicate drugs. i. Bowel regimen; bisacodyl suppository, Colace and Miralax. ii. Antidepressants; venlafaxine and trazadone. b. The updates to the comprehensive assessment for recertification, dated 1/13/22 and 3/14/22 identified medications were reconciled and included assessment of all required components. Duplicate therapy and drug interactions identified by checkmark. Duplicate drugs were not identified. c. During a home visit observation on 3/23/22 at 10:20 am, with Staff E, Registered Nurse, RN the surveyor reviewed the medication profile and the patients medications. The patient stated that she has not used the bisacodyl suppository in at least 6 months. The epinephrine dated 6/2018 was expired. The agency failed to complete an accurate and up to date drug regimen review with the comprehensive assessment. 2. Patient #4 had a start of care date of 7/01/21. Clinical record review revealed the following: a. The Plans of Care, resumption of care, (ROC) dated 12/28/21 to 2/05/22 and Resertification dated 2/26/22 to 4/26/22 included orders for duplicate drugs. i. Diabetic medications; novolog, trulicity and basaglar ii. Urinary medications; finasteride and toviaz iii. Anti hypertensives; lisinopril and carvedilol iiii. Respiratory; albuterol and atrovent b. The Comprehensive Assessment, ROC dated 12/27/21 and Recertification dated 2/21/22 identified the medication reconciliation had been completed. Duplicate medications were not identified. The agency failed to complete an accurate and up to date drug regimen review with the comprehensive assessment. 3. Patient #5 had a start of care date of 10/6/21 . Clinical record review revealed the following: a. The Plan of Care, dated 2/3/22 to 4/3/22 included orders for duplicate drugs. i. Blood pressure medications; metoprolol and hydrochlorothiazide b. The update to the comprehensive assessment for recertification, dated 2/02/22 identified medications were reconciled. No medication issues were identified including duplicate drugs. The agency failed to complete a drug regimen review with the comprehensive assessment.

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 clinical record review, agency policy review, patient/caregiver interview, physician interview, and agency staff interview, the agency was found operating out of compliance with with the requirements of this Condition of Participation for the following reasons: 1) failed to ensure each patient received services that were established by a physician or notified the physician of the need to alter the Plan of Care(G572); 2) failed to ensure all supplies/equipment/medications/treatments required by the patient to meet his/her needs were included on each patient's Plan of Care (G574); The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 139 patients.

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 agency policy review, clinical record review, and physician, caregiver and agency staff interviews, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 5 of 11 sampled patients (Patients #3, #6, #7, #8 and #10). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 3. Patient #6 had a start of care date of 6/13/2019. Clinical record review and associated agency interviews revealed the following: a. The Plan of Care, dated 11/29/2021 to 1/27/2022, included physician orders for home health aide visits 5 times weekly for 8 weeks and 4 times weekly for 1 week. The electronic clinical record included documentation of only 1 home health aide visit during the last week of the Plan of Care certification period. The electronic clinical record included documentation, titled Missed Visit, dated 1/25/2022, 1/26/2022 and 1/27/2022. Each of the Missed Visit notes documented no home health aide service was provided as "patient cancelled care and refused to reschedule- family able to assist patient". Each of the Missed Visit notes documented the physician had not been notified of the missed visits. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visits on 1/25,26,27/2022. b. The Plan of Care, dated 1/28/2022 to 3/28/2022, included physician orders for home health aide visits 1 time weekly for 1 week; 5 times weekly for 8 weeks; and 1 time weekly for 1 weeks. The electronic clinical record included documentation of only 3 home health aide visits during the third week of the Plan of Care certification period (2/6-12/2022). The electronic clinical record included documentation, titled Missed Visit, dated 2/9/2022 and 2/10/2022. Each of the Missed Visit notes documented no home health aide service was provided as "patient out of town." Each of the Missed Visit notes documented the physician had not been notified of the missed visits. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visits on 2/9/2022 and 2/10/2022. c. Review of the agency staff list revealed that Staff O, primary Home Health Aide for Patient #6, resigned on 2/14/2022. The physician's interim order, dated 2/14/2022, decreased the patient's home health aide services to 3 times weekly for the rest of the certification period. The hard copy paper clinical record included the physician signed copy of the interim order. The electronic clinical record included documentation of only 2 home health aide visits during the week of 2/20-26/2022. The electronic clinical record included documentation, titled Missed Visit, dated 2/21/2022, documenting "cancellation of care- physician notified". The hard copy clinical record included a physician signed copy of the Missed Visit note for 2/21/2022. The electronic clinical record included documentation of only 1 home health aide visit during the week of 2/27-3/5/2022; no home health aide visits during the week of 3/6-12/2022; and only 2 home health aide visits during the week of 3/13-19/2022. The electronic clinical record included missed visit documentation for 3/2,3/2022 and 3/7,9,11/2022. Each of the Missed Visit notes documented no home health aide service was provided as "primary (aide) unavailable, offered patient replacement and patient refused wanting stranger in home- Clinical Manager reported with primary skilled nurse to assess and address any personal care/ADLs (activities of daily living) that may need addressed during skilled nurse visit." Each of the Missed Visit notes documented the Clinical Manager notified the physician of the missed visits. During agency staff interview on 3/29/2022 at 3:00 PM, the Clinical Manager reported if the aide was unable to see the patient and she directed the nurse to assess and address personal care needs during the skilled nurse visit, she would expect the nurse to document the assessed needs and any tasks the nurse assisted the patient with during the skilled nurse visit within the skilled nurse visit note. The electronic clinical record included documentation of skilled nurse visit notes on 3/2/2022 and 3/7/2022. Both visits lacked documentation of the skilled nurse assessment of the personal care needs of the patient on either day and lacked documentation of the provision of any assistance with personal care tasks during the skilled nursing visits on either day. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visits on 3/2,3,7,9,11/2022. d. The surveyor contacted the patient's physician office by telephone on 3/24/2022 at 10:15 AM. The physician's registered nurse contacted the surveyor back on 3/24/2022 at 2:05 PM. The surveyor requested the nurse review the patient's clinic record for either documentation of Missed Visit notes sent to the clinic by facsimile from Nurse At Home or documentation of telephone or in-person contact to report variations in the physician ordered frequency for home health aide visits for Patient #6 in January, February and March 2022. The nurse indicated a plan to review the clinic record and get back with the surveyor. On 3/25/2022 at 1:50 PM, the Medical Office Manager from Patient #6's physician's clinic contacted the surveyor by telephone. Interview with the Medical Office Manager revealed the clinic record lacked any contact, either by facsimile, telephone or in-person, during January 2022 except home health Plan of Care. The Medical Office Manager reported the clinic record included a home health Plan of Care for the period including February 2022, a physician interim order, dated 2/14/2022, decreasing the aide services to 3 times per week and one Missed Visit note, dated 2/21/2022, all received by facsimile from the agency. The clinic record lacked any other documents sent from Nurse At Home, documentation of telephone contact or in-person contact in February 2022. The Medical Office Manager reported the clinic record included a Plan of Care covering March 2022 but lacked any other documents sent by facsimile or any documentation of in-person or telephone contact with Nurse at Home. The Medical Office Manager reported all documentation received from home health agencies by facsimile are maintained in the clinic record of the patient receiving the home health services. e. During patient interview on 3/24/2022 at 2:40 PM, Patient #6 reported receiving skilled nursing and home health aide services from Nurse At Home. The patient reported "we don't tell them not to come, they just don't have enough nurses". The patient reported "sometimes they don't have anybody to send so my (spouse) does (his/her) best to help. (He/she) has a bum shoulder and can't help too much." "Once they didn't come for a whole week because they didn't have have a nurse so that was tough but we make work." The main home health aide working with Patient #6 (Staff O) resigned and "They used to come 5 times per week but then they decreased to 3 times in one week in February but I think that is enough." The agency failed to provide home health aide services at the frequency ordered by the physician in the Plans of Care. The agency failed to contact the physician to notify the physician of the inability to provide services as needed by the patient and ordered by the physician. 4. Patient #7 had a start of care date of 10/9/2020 and was discharged from agency services on 10/1/2021. The agency readmitted the patient to services on 10/25/2021 and the patient was discharged from agency services on 12/20/2021. Clinical record review with associated interviews revealed the following: The Plan of Care, dated 10/25/2021 to 12/23/2021, included physician orders for home health aide visits 2 times weekly for 1 week; 5 times weekly for 7 weeks and 4 times weekly for 1 week. The same Plan of Care included physician orders for skilled nurse visits 2 times weekly for 9 weeks. a. The electronic clinical record lacked documentation of any home health aide visits during the first week of service (10/25-30/2021). The electronic clinical record included documentation, titled Missed Visit, dated 10/28/2021 and 10/29/2021. Each of the Missed Visit notes documented no home health aide service was provided as "client refused care". Each of the Missed Visit notes documented the physician had not been notified of the missed visits. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visits on 10/28,29/2021. b. The electronic clinical record lacked documentation of any home health aide or skilled nursing visits during the second week of service. (10/31-11/6/2021). The electronic clinical record included documentation, titled Missed Visit, dated 11/1/2021, 11/2/2021, 11/3/2021, 11/4/2021 and 11/5/2021. Each of the Missed Visit notes documented no home health aide service was provided as "no answer locked door". Each of the Missed Visit notes documented the physician had not been notified of the missed visits. The electronic clinical record also included documentation, titled Missed Visit, dated 11/5/2021. The Missed Visit note documented no skilled nurse visit was provided as "no answer to locked door.", indicating the physician was notified of the missed visit. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits or skilled nurse visits . The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visits on 11/1,2,3,4,5/2021 or the skilled nurse on 11/5/2021. c. The electronic clinical record included documentation of only 4 home health aide visits during the weeks of 11/14-20/2021. The electronic clinical record included documentation, titled Missed Visit, dated 11/19/2021. The Missed Visit note documented no home health aide service was provided as "no answer locked door". The Missed Visit note documented the physician had not been notified of the missed visit. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visit on 11/19/2021. d. The electronic clinical record included documentation of only 3 home health aide visits during the week of 11/21-27/2021. The electronic clinical record included documentation, titled Missed Visit, dated 11/23/2021 and 11/25/2021. The Missed Visit notes documented no home health aide service was provided as "no answer to phone call". The Missed Visit note documented the physician had not been notified of the missed visits. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy chart lacked documentation of any Missed Visit notes signed by the physician verifying notification of the missed home health aide visits on 11/23,25/2021. e. The electronic clinical record included documentation of only 3 home health aide visits during the week of 11/28-12/4/2021. The electronic clinical record included documentation, titled Missed Visit, dated 12/2/2021. The Missed Visit note documented no home health aide service was provided due to "cancellation of care". The Missed Visit note documented the physician had not been notified of the missed visit. The electronic clinical record lacked documentation of a missed visit note, dated 12/3/2021. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy chart lacked documentation of any Missed Visit notes signed by the physician verifying notification of the missed home health aide visits on 12/2,3/2021. f. The electronic clinical record included documentation of only 3 home health aide visits during the week of 12/5-11/2021. The record documented the aide went to the patient's home on 12/7/2021; however, the patient refused all personal care assigned. The electronic clinical record included documentation, titled Missed Visit, dated 12/9/2021. The Missed Visit note documented no home health aide service was provided as "family-caregiver able to assist patient". The Missed Visit note documented the physician had not been notified of the missed visit. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits or the patient's refusal of all tasks on 12/7/2021. The hard copy chart lacked documentation of any Missed Visit notes signed by the physician verifying notification of the missed home health aide visits on 12/7,9/2021. g. The electronic clinical record included documentation of only 4 home health aide visits during the week of 12/12-18/2022. The electronic clinical record included documentation, titled Missed Visit, dated 12/17/2021. The Missed Visit note documented no home health aide service was provided as "cancellation of care". The Missed Visit note documented the physician had not been notified of the missed visit. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency. The hard copy chart lacked documentation of any Missed Visit notes signed by the physician verifying notification of the missed home health aide visits on 12/17/2021. h. The surveyor contacted the patient's physician office by telephone on 3/24/2022 at 11:40 AM. The surveyor spoke with the physician's registered nurse. The surveyor requested the nurse review the patient's clinic record for either documentation of Missed Visit notes sent to the clinic by facsimile from Nurse At Home or documentation of telephone or in-person contact to report variations in the physician ordered frequency for home health aide visits and skilled nurse visits for Patient #7 in October, November and December 2021. The nurse indicated a plan to review the clinic record and get back with the surveyor. On 3/24/2022 at 11:50 AM, Patient #7's physician's clinic nurse contacted the surveyor by telephone. Interview with the nurse revealed the clinic record lacked any contact, either by facsimile, telephone or in-person, during October or November 2021 except home health Plan of Care. The nurse reported the clinic record documented a telephone call was received on 12/20/2021 to report a missed home health aide visit on 12/20/2021. The clinic record lacked any other documents sent from Nurse At Home, documentation of telephone contact or in-person contact in December 2021. The nurse reported all documentation received from home health agencies by facsimile are maintained in the clinic record of the patient receiving the home health services and telephone calls or in-person contact is documented. i. During patient caregiver interview on 3/24/2022 at 12:30 PM, Patient #7's primary caregiver verified the patient received skilled nursing and home health aide services under 2 episodes of care. When the patient was readmitted to service in October "I told the nurse 3 times that when I know they are coming, I will leave the door unlocked just come on in. Had alot of no-shows.... didn't come at times when they were supposed to. One day the nurse came, says she knocked but no answer. She took a picture of herself at my door and sent it to me. She didn't even try the door knob.... Did go a whole week without the aide but we were here. Other times no one showed. Other times we had scattered appointments but most times we would get a call saying they can't come or want to change times." (Surveyor had previously spoken to Patient #7's primary caregiver regarding a different issue on 3/21/2022 at 4:15 PM and during that interview the caregiver did report she refused to allow the home health aide who previously cared for Patient #7 to return to the home. The agency had scheduled Staff J, Home Health Aide, to go to the patient's home on 10/28/2021 and 10/29/2021 after the caregiver told the admitting nurse of the refusal during the start of care assessment visit. See additional information in G478) The agency failed to provide home health aide services at the frequency ordered by the physician in the Plans of Care. The agency failed to contact the physician to notify the physician of the inability to provide services as needed by the patient and ordered by the physician. 5. Patient #8 had a start of care date of 8/17/2017. Clinical record review and associated interviews revealed the following: The Plan of Care, dated 1/23/2022 to 3/23/2022, included physician orders for home health aide visits 5 times weekly for 7 weeks and 4 times weekly for 1 week. The Plan of Care documented the patient was a bedbound adult patient with congenital disabilities being cared for by both parents. a. The electronic clinical record included documentation of only 3 home health aide visits during the week of 1/23-29/2022. The electronic clinical record included documentation, titled Missed Visit, dated 1/27/2022. The Missed Visit note documented no home health aide service was provided as "cancellation of care, caregiver at home to help". The Missed Visit note documented the physician had not been notified of the missed visit. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visit on 1/27/2022. No home health aide service was provided on 1/28/2022; however, the clinical record did not address this as a missed visit. b. The electronic clinical record included documentation of only 4 home health aide visits during the week of 1/30-2/5/2022. No home health aide service was provided on 2/2/2022; however, the clinical record did not address this as a missed visit. c. The electronic clinical record included documentation of only 3 home health aide visits during the week of 2/6-12/2022. The electronic clinical record included documentation, titled Missed Visit, dated 2/10/2022. The Missed Visit note documented no home health aide service was provided as "family-caregiver able to assist patient". The Missed Visit note documented the physician had not been notified of the missed visits. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy chart lacked documentation of any Missed Visit notes signed by the physician verifying notification of the missed home health aide visit on 2/10/2022. d. Review of the agency staff list revealed that Staff O, Home Health Aide, provided routine services to Patient #8. The aide resigned on 2/14/2022. The electronic clinical record included a physician's interim order, dated 2/14/2022, decreasing the aide visits to 3 times per week. The electronic clinical record included documentation of only 1 home health aide visit during the week of 2/13-19/2022. The electronic clinical record included documentation, titled Missed Visit, dated 2/15/2022 and 2/16/2022. The Missed Visit notes documented no home health aide service was provided due to "no answer to locked door or phone call". The Missed Visit note documented the physician had been notified of the missed visit. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy chart lacked documentation of any Missed Visit notes signed by the physician verifying notification of the missed home health aide visits on 2/15,16/2022. e. The electronic clinical record included documentation of only 1 home health aide visit during the weeks of 2/27-3/5/2022 and 3/6-12/2022. The electronic clinical record included missed visit documentation for 3/3/2022 and 3/7/2022. Each of the Missed Visit notes documented no home health aide service was provided as "primary (aide) unavailable, offered patient replacement and patient refused wanting stranger in home- Clinical Manager reported with primary skilled nurse to assess and address any personal care/ADLs (activities of daily living) that may need addressed during skilled nurse visit." Each of the Missed Visit notes documented the Clinical Manager notified the physician of the missed visits. During agency staff interview on 3/29/2022 at 3:00 PM, the Clinical Manager reported if the aide was unable to see the patient and she directed the nurse to assess and address personal care needs during the skilled nurse visit, she would expect the nurse to document the assessed needs and any tasks the nurse assisted the patient with during the skilled nurse visit within the skilled nurse visit note. The electronic clinical record included documentation of skilled nurse visit notes on 3/3/2022 and 3/7/2022. Both visits lacked documentation of the skilled nurse assessment of the personal care needs of the patient on either day and lacked documentation of the provision of any assistance with personal care tasks during the skilled nursing visits on either day. The electronic clinical record lacked documentation of telephone calls to the physician to report the change in the ordered frequency for home health aide visits. The hard copy paper chart lacked documentation of any Missed Visit notes signed by the physician verifying notification for the missed home health aide visits on 3/3,7/2022. f. During patient caregiver interview on 3/28/2022 at 8:30 PM, Patient #8's primary caregiver reported the patient is bedbound and never left alone. Reported the patient is only up in a wheelchair for appointments when necessary. Reports "the aides do a good job but they leave and the agency has a hard time replacing them. They have alot of no-shows- they don't call or they don't have anyone to send. We never refuse care. In February (2022) they decreased the aide to 3 times per week because the main girl moved on to another job and they couldn't find somebody. If they don't come, my husband and I have to care for (the patient)". g. The surveyor contacted the patient's physician office by telephone on 3/29/2022 at 8:10 AM. The surveyor spoke with the Office Manager of the clinic. The Office Manager needed to check with Administration to determine the process for releasing information about the patient to the surveyor. On 3/29/2022, the attorney for the hospital owned clinic contacted the surveyor. Information requested by the attorney given. Someone from the clinic will review the patient's clinic record for either documentation of Missed Visit notes sent to the clinic by facsimile from Nurse At Home or documentation of telephone or in-person contact to report variations in the physician ordered frequency for home health aide visits and skilled nurse visits for Patient #8 in January, February and March 2022. Someone will report the information when completed. On 4/1/2022 at 10:36 AM, a representative from the clinic contacted the surveyor by email, reporting an inability to find any documentation of physician notification for the missed home health aide visits, missed skilled nurse visit or the inability to perform tasks as ordered from Nurse at Home. The agency failed to provide home health aide services at the frequency ordered by the physician in the Plans of Care. The agency failed to contact the physician to notify the physician of the inability to provide services as needed by the patient and ordered by the physician. Surveyors reviewed the above stated findings for Patients #3, #6, #7, #8, #10 with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey. According to the undated agency policy, titled Missed Visit Policy, patients shall be notified as soon as possible of alterations to the visit schedule. If there is a missed visit, services shall be provided as agreed upon by the patient and the agency. The agency staff will coordinate with the patient or the patient's authorized representative to reschedule a missed visit whenever possible, Sunday through Saturday. Family or caregiver is available, able, and willing to participation in patient's care when conditions warrant. If the agency admits patients with needs that require care or services delivered at specific times or times of day, the agency shall ensure qualified staff to ensure the needs of the patients are met. Interview on 3/21/22 at 10:35 AM with the Clinical Manager revealed since she took over as Clinical Manager on 1/31/22, if the frequency of visits is varied from the Plan of Care, the nurse will chart the missed visit, select a reason for the missed visit and send the missed visit to the physician to report in a communication note. The missed visit note would be kept in the patient's hard paper chart after returned to the agency by the physician. The Clinical Manager also reported has had trouble staffing home health aide services and states the agency refuses the referral if unable to meet the needs of the patient and also just hired a certified nursing assistant. She further stated the agency has a contract with an agency if needed to provide aide services. On 3/28/22 at 2:30 PM, the Clinical Manager verified again that if the physician returns the missed visit sheets, they are put into the hard paper chart. 1. Patient #3 had a start of care date of 8/14/18. Clinical record review revealed: a. The Plans of Care, dated 11/26/22 to 1/24/22 and 1/25/22 to 3/25/22, included physician orders for home health aide visits 5 times every week to provide assistance with personal cares and activities of daily living as indicated by limitations on fn functional and physical status impeding care. b. For the week of 1/23/22, the clinical document lacked documentation of any home health aide visits. c. The missed visit note, dated 1/24/22, documented the visit was missed due to the patient not answering the door and the door was locked. d. The missed visit notes dated 1/25/22, 1/26/22, 1/27/22, and 1/28/22, documented the home health aide had COVID. The clinical record lacked documentation of physician notification of the missed home health aide visits. 2. Patient #10 had a start of care date of 1/8/21. Clinical record review revealed: a. The Plan of Care, dated 9/5/21 to 11/3/21, included physician orders for home health aide visits 2 times every week to provide assistance with personal cares and activities of daily living as indicated by limitations on functional and physical status impeding care. b. For the week of 10/17/21, the clinical record contained one home health aide visit note, dated 10/20/21. c. The missed visit note, dated 10/22/21, documented the visit was missed due to the patient refusal. The clinical record lacked documentation of physician notification of the missed home health aide visit. d. For the week of 10/31/21, the clinical record contained one home health aide visit note, dated 11/4/21. e. The missed visit note, dated 11/3/21, documented the visit was missed due to the patient not answering the phone. The clinical record lacked documentation of physician notification of the missed home health aide visit.

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 clinical record review, home visit observation, patient/caregiver interview and agency staff interview, the agency failed to ensure the accurate completion of all components of the Plan of Care, including a list of current medications taken by the patient and/or equipment/supplies used to meet the patient's individualized needs for 6 of 9 sampled patients (Patients #1, #2, #3, #6, #8 and #11 ). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive home care services according to assessed needs and physician orders. 5. Patient #6 had a start of care date of 6/13/2019. Clinical record review and associated interviews revealed the following: a. The Plans of Care, dated 8/1/2021 to 9/29/2021, 9/30/2021 to 11/28/2021, 11/29/2021 to 1/27/2022 and 1/28/2022 to 3/28/2022, included Dulcolax laxative as a medication taken by the patient. The Plans of Care documented the patient took one dose of the Dulcolax laxative every day "per label instructions". The Plans lacked a dosage of the Dulcolax in one dose. b. The Plans of Care, dated 8/1/2021 to 9/29/2021, 9/30/2021 to 11/28/2021, included Invokana 300 mg, a diabetic medication, as taken by the patient daily. The same Plans of Care included canagliflozin, a generic of Invokana, 100 mg taken by the patient daily. On 3/24/2022 at 2:05 PM, the surveyor contacted the patient's physician's office. During interview, the physician's RN reported the patient previously took the generic canagliflozin 100 mg daily. The medication/dosage changed on 2/25/2021 to Invokana, increasing the 100 mg dosage to 300 mg daily and had remained at that dosage ever since. c. The update to the comprehensive assessment at the time of recertification, dated 1/26/2022, documented the patient used a CPAP (a portable machine with a mask worn at night to treat sleep apnea using continuous positive airway pressure). The Plan of Care, dated 1/28/2022 to 3/28/2022, lacked inclusion of the CPAP as equipment used by the patient to meet his/her needs. On 3/24/2022 at 2:05 PM, the surveyor contacted the patient's physician's office. During interview, the physician's RN reported the patient previously used a CPAP prior to 10/12/2020. On 10/12/2020, following a sleep study, the CPAP was changed to a BIPAP (a similar portable machine with a mask worn at night to treat sleep apnea using bilevel positive airway pressure) and the patient had used ever since. The Plans of Care, dated 8/1/2021 to 9/29/2021, 9/30/2021 to 11/28/2021, 11/29/2021 to 1/27/2022 and 1/28/2022 to 3/28/2022, lacked inclusion of the BIPAP machine as equipment used by the patient to meet his/her needs. 6. Patient #8 had a start of care date of 8/17/20217. Clinical record review and associated interviews revealed the following: a. The updates to the comprehensive assessment at the time of recertification, dated 9/24/2021, 1/21/2022 and 3/22/2022, documented Patient #8 experienced urinary incontinence requiring the use of incontinence briefs; was bedridden, only getting out of bed to go to appointments; and used a wheelchair for transport to appointments. b. The update to the comprehensive assessment at the time of resumption of care, dated 11/23/2021, documented Patient #8 experienced urinary incontinence requiring the use of incontinence briefs; was bedridden, only getting out of bed to go to appointments; and used a wheelchair for transport to appointments. c. During caregiver interview on 3/28/2022 at 8:30 PM, the primary caregiver of Patient #8 reported the patient wore incontinence briefs, pads on the bed for urine overflow and used a pump mechanical lift with a sling for transfers into a wheelchair if appointments required. The Plans of Care, dated 9/25/2021 to 11/23/2021, 11/24/2021 to 1/22/2022 and 1/23/2022 to 3/23/2022, lacked inclusion of incontinence briefs, incontinence pads and the mechanical lift as medical equipment and supplies used by the patient to meet his/her needs. The surveyors reviewed the above stated findings for Patients #1, #2, #3, #6, #8 and #11 with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey. 2. Patient #1 had a start of care date of 1/18/21. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 1/18/21 to 3/18/21, 11/14/21 to 1/12/22, 1/13/22 to 3/13/22, and 3/14/22 to 5/12/22 included orders for Memantine 28 milligrams (mg) extended release twice daily. b. The Medication Profile, for the episode 3/14/22 to 5/12/22, provided to the surveyor for the observation home visit included orders for Memantine 28 milligrams (mg) extended release twice daily. During a home visit observation on 3/23/22 at 11:05 AM, with Staff C, Physical Therapist (PT), the patient's caregiver and the surveyor reviewed the patient's medications. The caregiver sets up and administers the patient's medications to the patient due to the patient's diagnosis of Alzheimer's disease. The surveyor observed the patient's medications and a bottle of Memantine 10 mg with orders to take twice daily. The caregiver verbalized the dosage was changed from 28 mg to 10 mg at the end of 2019 or beginning of 2020 due to the patient being excessively sleepy. The Plan of Care lacked the correct dosage of Memantine used by the patient. c. The Plans of Care, dated 1/18/21 to 3/18/21, 11/14/21 to 1/12/22, 1/13/22 to 3/13/22, and 3/14/22 to 5/12/22 included orders for Fluticasone-Salmeterol 250 micrograms -50micrograms (mcg) inhalation powder with instructions to administer 1 puff twice daily. d. The Medication Profile, for the episode 3/14/22 to 5/12/22, provided to the surveyor for the observation home visit included orders for Fluticasone-Salmeterol 250 micrograms -50micrograms (mcg) inhalation powder with instructions to administer 1 puff twice daily . During the same home visit observation on 3/23/22 at 11:05 AM, with Staff C, Physical Therapist (PT), the patient's caregiver and the surveyor reviewed the patient's medications. The caregiver reported can't remember when stopped the fluticasone, but feels was prior to admission to the home health agency. The Plan of Care included an order for the Fluticasone-Salmetrol that was no longer being used by the patient. e. The Plans of Care, dated 1/18/21 to 3/18/21, 11/14/21 to 1/12/22, 1/13/22 to 3/13/22, and 3/14/22 to 5/12/22, identified the following as medical equipment and supplies used by the patient: hoyer lift, hospital bed, and walker. During the same home visit observation on 3/23/22 at 11:05 AM, with Staff C, Physical Therapist (PT), the surveyor observed the patient laying in a hospital bed with rails with an air mattress overlay. The caregiver reported has had the bed rails and air mattress for as long as has had the hospital bed and admitted to the hospital bed (almost one year ago). f. The Plans of Care lacked identification of the bed rails and air mattress as medical equipment/supplies used to meet the patient's needs. During the same home visit observation on 3/23/22 at 11:05 AM, with Staff C, Physical Therapist (PT), the surveyor observed the patient caregiver putting a seat cushion in a lift chair for the patient. The caregiver reported has had the lift chair as long as had the hospital bed and admitted to the agency. The caregiver has had the cushion more than one month. g. The Plans of Care lacked identification of the lift chair and seat cushion as medical equipment/supplies used to meet the patient's needs. h. Skilled nursing visit notes, dated 1/18/21, 11/9/21, 1/1/11/22, and 3/9/22, documented the patient's urinary incontinence. During the same home visit observation on 3/23/22 at 11:05 AM, with Staff C, Physical Therapist (PT), the surveyor observed the patient wearing depends. The patient's caregiver reported the patient's need for incontinence supplies for at least a year due to the patient's mental capacity. i. The Plans of Care lacked identification of incontinence supplies as medical equipment/supplies used to meet the patient's needs. 3. Patient #3 had a start of care date of 8/14/18. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 9/27/21 to 11/25/21, 11/26/21 to 1/24/22, 1/25/22 to 3/25/22, identified the following as medical equipment and supplies used by the patient: tub/shower bench, cane, walker, wheelchair and grab bars. During a home visit observation on 3/23/22 at 10:00 AM, with Staff G, Registered Nurse (RN), the surveyor observed the patient patient's care while the patient sat on the edge of the bed. The patient had a pure wick catheter system by the bed. The RN reported the patient bought it on her own some time ago. b. Skilled nurse visit note, dated 1/17/22, documented presence of the pure wick catheter system. c. The Plans of Care, 11/26/21 to 1/24/22 and 1/25/22 to 3/25/22, lacked identification of the pure wick catheter system as medical equipment/supplies used to meet the patient's needs. During the same home visit observation on 3/23/22 at 10:00 AM, with Staff G, Registered Nurse (RN), the surveyor observed a bedside stand near the patient's bed. The patient reported use of the bedside stand for about 6 months. d. The Plans of Care, 9/27/21 to 11/25/21, 11/26/21 to 1/24/22 and 1/25/22 to 3/25/22, lacked identification of the bedside stand as medical equipment/supplies used to meet the patient's needs. During the same home visit observation on 3/23/22 at 10:00 AM, with Staff G, Registered Nurse (RN), the surveyor observed the patient was wearing depends. The patient reported use of depends for a couple of years. e. The Plans of Care, 9/27/21 to 11/25/21, 11/26/21 to 1/24/22 and 1/25/22 to 3/25/22, lacked identification of incontinent supplies as medical equipment/supplies used to meet the patient's needs. During the same home visit observation on 3/23/22 at 10:00 AM, with Staff G, Registered Nurse (RN), the surveyor observed the patient's bed had a bed cane on it. The patient reported use of the bed cane for about 6 months. f. The Plans of Care, 9/27/21 to 11/25/21, 11/26/21 to 1/24/22 and 1/25/22 to 3/25/22, lacked identification of the bed cane as medical equipment/supplies used to meet the patient's needs. 4. Patient #4 had a start of care date of 10/22/21 and a discharge date of 12/17/22. Clinical record review revealed the following: a. The Plan of Care, dated 10/22/21 to 12/20/21, identified the following as medical equipment and supplies used by the patient: bedside commode, elevated toilet seat, nebulizer, oxygen, and walker. b. Skilled nurse visit notes, dated 10/29/22, 11/5/21, 11/12/21, 11/19/21, 12/3/21, , documented the nurse educated the patient on incentive spirometer use. c. The Plan of Care, 10/22/21 to 12/20/21, lacked identification of the incentive spirometer as medical equipment/supplies used to meet the patient's needs. Findings include: 1. Patient #2 had a start of care date of 3/25/2020. Clinical record review and home visit observation revealed the following: a. The Plans of Care, dated 1/14/22 to 3/14/22 and 3/15/22 to 5/13/22 failed to identify the patient used incontinent supplies, briefs. b. The skilled nurse visit notes dated 1/20, 1/25, 2/2, 2/9, 2/16, 2/23, 3/2, 3/9 and 3/23 documented the patient wears depends. The patient is unable to make it to the bathroom and refuses to use the bedside commode. c. During a home visit observation on 3/23/22 at 10:20 am, with Staff E, Registered Nurse, RN the surveyor observed the patient wearing incontinence briefs. The Plan of Care failed to include all supplies, used by the patient.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on agency policy review, review of the agency's vaccination tracking forms, personnel file review and agency staff interview, the agency failed to accept religious exemption forms for 4 of 4 contracted staff (Staff C, Staff G, Staff H, and Staff I) documenting exemption requests including status pending and granted, failed to maintain policies/procedures including a process for ensuring recognized clinical contraindications to vaccine support request for medical exemptions, including the provider themselves, not the employee recommends the exemption, and failed to maintain policies/procedures including a process for tracking and securely documenting temporary delays of vaccine associated with acute illness, monoclonal antibodies or convalescent plasma use. The agency reported a current census of 139 patients; employed 14 staff directly and employed 10 staff by arrangement at the time of the survey. The agency reported 19 fully vaccinated staff; 1 with granted non-medical exemptions and 0 granted exemptions for medical reasons or temporary delay of the vaccination. Failure to approve exemptions and maintain policies and procedures including process for tracking and securely documenting exemption requests and status pending/granted, a process for ensuring recognized clinical contraindications to vaccine support requests for medical exemption, including the provider not the employee themselves recommends the exemption, and a process for tracking and securely documenting temporary delay of vaccine for acute illness, monoclonal antibodies or convalescent plasma use, placed agency patients and other agency employees at an increased risk of exposure/transmission of the COVID-19 virus. Findings include: According to the agency policy/procedure, titled COVID-19 Mandatory vaccination policy and dated 3/14/2022, employees may request for an exemption from this mandatory vaccination policy if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination. Employees also maybe legally entitled to a reasonable accommodation if they cannot be vaccinated because of a documented medical condition approved by a licensed medical professional and/or vaccination conflicts with sincerely held religious belief, practice, or observance. Any employee requesting an exemption, medical/religious, will be provided a form to fill out requesting said exemption. Once it is completed and signed, it will be reviewed by the agency Administrator and Clinical Manager, with the consideration of safety of the patients and other employees as the final determination of approval. Personnel file review revealed: 1. Staff C, Physical Therapist, was employed by agreement with the agency. The contracted employee used a form titled, Vaccine Religious Exemption Request, that included a release of the request to the contracted home health agencies associated with the therapy company. The request was completed on 12/2/21. The form had a blank spaces at the end including the following: RETURN THIS FORM TO EMPLOYER, Office Use Only, Exemption Review Date, Approval Date, Denial Date, Reason for Denial, and included spaces for Two Signatures and Dates. This area was blank and no exemption approval date was identified. Interview with Staff C, Physical Therapist on 3/28/22 at 9:49 AM, revealed the therapist believed the head of the therapy company accepted the exemption request. 2. Staff G, Speech Therapist, was employed by agreement with the agency. The contracted employee used a form titled, Vaccine Religious Exemption Request, that included a release of the request to the contracted home health agencies associated with the therapy company. The request was completed on 12/3/21. The form had a blank spaces at the end including the following: RETURN THIS FORM TO EMPLOYER, Office Use Only, Exemption Review Date, Approval Date, Denial Date, Reason for Denial, and included spaces for Two Signatures and Dates. This area was blank and no exemption approval date was identified. Interview with Staff G, Speech Therapist on 3/28/22 at 8:52 AM, revealed the therapist believed the head of the therapy company accepted the exemption request. 3. Staff H, Physical Therapy Assistant, was employed by agreement with the agency. The contracted employee used a form titled, Vaccine Religious Exemption Request, that included a release of the request to the contracted home health agencies associated with the therapy company. The request was completed on 12/1/21. The form had a blank spaces at the end including the following: RETURN THIS FORM TO EMPLOYER, Office Use Only, Exemption Review Date, Approval Date, Denial Date, Reason for Denial, and included spaces for Two Signatures and Dates. This area was blank and no exemption approval date was identified. Interview with Staff H, Physical Therapy Assistant on 3/28/22 at 8:52 AM, revealed the assistant believed the head of the therapy company accepted the exemption request. 4. Staff I, Physical Therapist, was employed by agreement with the agency. The contracted employee used a form titled, Vaccine Religious Exemption Request, that included a release of the request to the contracted home health agencies associated with the therapy company. The request was completed on 1/3/22. The form had a blank spaces at the end including the following: RETURN THIS FORM TO EMPLOYER, Office Use Only, Exemption Review Date, Approval Date, Denial Date, Reason for Denial, and included spaces for Two Signatures and Dates. This area was blank and no exemption approval date was identified. Interview with Staff I, Physical Therapist on 3/28/22 at 12:37 PM, revealed the therapist believed the head of the therapy company accepted the exemption request. Interview with the Clinical Manager on 3/21/22 at 3:00 PM reported she missed the requirements for Tier 1 of the vaccine mandate and began working on things 2/22/22. The therapy business refused to follow agency policy for weekly testing if unvaccinated and were planning to discontinue the therapy contract. The agency discussed removal of the weekly testing requirement and updated the policy on 3/14/22, removing the requirement of weekly testing. The Clinical Manager stated, "I didn't approve the religious exemptions for the therapy staff, the head of therapy did. I guess you could say once we came to an agreement, I approved them across the board but didn't sign anything. I sent the policy for contingency plan for unvaccinated workers to the head of therapy and received an email stating she alerted her staff about the requirements. Review of agency email, dated 3/21/22, documented the agency policy was accepted dated 3/14/22 and a copy of the policy was sent to all staff members. Review of the agency policy/procedure, titled COVID-19 Mandatory vaccination policy and dated 3/14/2022, lacked a process for tracking and securely documenting exemption requests including status pending or granted, a process for ensuring recognized clinical contraindications to vaccine support requests for medical exemption, including the provider not the employee recommends the exemption, and a process for tracking and securely documenting temporary delay of vaccine (acute illness, monoclonal antibodies, or convalescent plasma use). The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, personnel file review, patient/caregiver interview, and agency staff interview, the agency was found operating out of compliance with with the requirements of this Condition of Participation for the following reasons: 1) failed to ensure home care aides received competency testing for extra skills assigned by the nurse as an extension of nursing services (G768); 2) failed to ensure all home health aides are assigned to a specific patient by a registered nurse and all assignments are specific and individualized to meet the patients needs (G798); and 3) failed to ensure all home health aides provided services as ordered b the physician, are included in the Plan of Care, are permitted under state law and are consistent with home health aide training (G800); The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 139 patients.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on agency policy review, personnel file review and staff interview, the agency failed to ensure the home health aides successfully completed competencies in all home health aide skills that exceed basic skills, which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 1 of 2 sampled home health aides assigned extra skills (Staff D). Failure to ensure home health aides were competent in any assigned skill which exceeds the level of basic home health aide skills, placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: According to the undated agency policy, titled Home Health Aide Care Plan, if the home health aide is assigned to perform delegated nursing functions, such as administering medications, i.e., eye drops, the aide must be oriented to the procedure by a registered nurse and the nurse must document return demonstration and/or other evidence of competency. Patient #3 had a start of care date of 8/4/18. The home health aide instructions directed the aide to apply compression stockings. The clinical record identified Staff D provided care to Patient #3. Staff D, Home Health Aide (HHA), had a hire date of 3/15/17. Staff D's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for application of compression stockings prior to providing care for Patient #3. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, and patient caregiver and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 7 of 8 sampled patients receiving home health aide services (Patients #1, #3, #4, #6, #7, #8 and #10). The agency reported 74 patients currently received care provided by a home health aide. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: 5. Patient #6 had a start of care date of 6/13/2019. Clinical record review and associated interviews revealed the following: The Plans of Care, dated 11/29/2021 to 1/27/2022 and 1/28/2022 to 3/28/2022, included physician orders for home health aide services 5 times weekly to assist with" personal care and activities of daily living as indicated by limitations on functional and physical status impeding self-care." The physician's interim order, dated 2/14/2022, decreased home health aide visits to 3 times weekly for the rest of the certification period. a. The Home Health Aide Care Plans, dated 11/24/2021 and 1/26/2022, directed the aide to provide a shower, shampoo, dressing assistance, apply lotion, comb hair, provide oral care, shave with an electric razor and clean/file the patient's nails. All of the tasks were assigned completed every visit. b. The Home Health Aide Visit notes, completed between 1/16/2022 and 3/19/2022, routinely documented Patient #6 refused assistance with showering, shampooing, oral care, shaving and nail care. (see G800 for additional information) c. During patient interview on 3/24/2022 at 2:40 PM, Patient #6 reported having the ability to shaving independently. The patient reported having no teeth or dentures so did not require oral care assistance, was independent with nail care and preferred to take a shower and shampoo at night. Patient #6 reported his/her adult child assisted with shower and shampoo in the evenings but not every day as the patient did not shower/shampoo every day. The patient reported the home health aides rarely assisted with shower/shampoo. d. The Home Health Aide Supervisory Visit notes, dated 1/17/2022, 1/31/2022, 2/14/2022, 2/28/2022 and 3/14/2022, each documented the aide was following the patient's RN assigned care plan, informed the supervisor of the patient's needs and changes as required and had no need to change the care plan tasks. The home health aide care plan included assigned tasks the patient was either independent with or had no need of assistance from the home health aide. The assignment was not individualized and specific to the patient's needs and abilities. 6. Patient #7 had a start of care date of 10/25/2021 and was discharged from agency services on 12/20/2021. Clinical record review and associated interviews revealed the following: The Plan of Care, dated 10/25/2021 to 12/23/2021, included physician orders for home health aide services 5 times weekly to assist with" personal care and activities of daily living as indicated by limitations on functional and physical status impeding self-care." a. The Home Health Aide Care Plan, dated 10/30/2021, directed the aide to provide a shower using a chair, shampoo, dressing assistance, apply lotion, comb hair, provide oral care, clean dentures, shave with an electric razor, clean/file the patient's nails and assist to the toilet/provide incontinence care. All of the tasks were assigned completed every visit. b. The Home Health Aide Visit notes, completed between 10/25/2021 and 12/19/2021, routinely documented Patient #8 refused assistance with comb hair, nail care, oral care, clean dentures and shaving. (see G800 for additional information) c. During patient caregiver interview on 3/24/2022 at 12:30 PM, Patient #7's sibling reported performing the following tasks routinely for the patient: shaving, combing hair, cleaning out the patient's mouth with swabs as he/she had no teeth and did not wear dentures and nail care. Patient #7's sibling reported residing with the patient and observed care provided to the patient by the home health aides. "The girls did shower, shampoo apply lotion to the body/Vaseline to the feet and helped with dressing." d. The Home Health Aide Supervisory Visit notes, dated 10/27/2021, 11/10/2021, 11/24/2021, 12/6/2021 and 12/20/2021, each documented the aide was following the patient's RN assigned care plan, informed the supervisor of the patient's needs and changes as required and had no need to change the care plan tasks. The home health aide care plan included assigned tasks the patient's primary caregiver always completed and the patient had no need of assistance from the home health aide. The assignment was not individualized and specific to the patient's needs and abilities. 7. Patient #8 had a start of care date of 8/17/2017. Clinical record review and associated interviews revealed the following: The Plan of Care, dated 1/23/2022 to 3/23/2022, included physician orders for home health aide services 4-5 times weekly to assist with" personal care and activities of daily living as indicated by limitations on functional and physical status impeding self-care." The physician's interim order, dated 2/14/2022, decreased home health aide visits to 3 times weekly for the rest of the certification period. a. The Home Health Aide Care Plans, dated 1/21/2022 and 1/27/2022, directed the aide to provide a bed bath, shampoo, dressing assistance, apply lotion, comb hair, provide oral care and clean/file the patient's nails. All of the tasks were assigned completed every visit. b. The Home Health Aide Visit notes, completed between 1/23/2022 and 3/19/2022, routinely documented Patient #8 refused assistance with shampooing 2 days per week, oral care and nail care. (see G800 for additional information) c. During patient caregiver interview on 3/28/2022 at 8:30 PM, Patient #8's parent reported the aides routinely perform a bed bath every visit, shampoo every other day, dress the patient in a shirt and incontinence brief and change the incontinence pad on the bed. Patient #8's parent reports routinely providing oral care to the patient and the nurse/podiatrist trim the patient's nails as the patient is diabetic. d. The Home Health Aide Supervisory Visit notes, dated 1/24/2022, 2/7/2022, 2/21/2022 and 3/21/2022, each documented the aide was following the patient's RN assigned care plan, informed the supervisor of the patient's needs and changes as required and had no need to change the care plan tasks. The home health aide care plan included assigned tasks the patient's primary caregiver routinely performed or tasks the patient had no need of assistance from the home health aide. The assignment was not individualized and specific to the patient's needs and abilities. The surveyors reviewed the above stated findings for Patients #1, #3, #4, #6, #7 and #8 with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey. 4. Patient #4 had a start of care date of 7/1/21. Clinical record review revealed the following: Clinical record review and associated interviews revealed the following: a. The Plans of Care, dated 12/28/21 to 2/25/22 and 2/26/22 to 4/26/22 , included physician orders for home health aide visits 3 times weekly then 5 times weekly. Completion of a comprehensive assessment and aide supervision every 60 days by a registered nurse. b. The home health aide assignment for the period of 12/28/21 through 4/26/22 , directed the following: i. Clean/File Nails every visit ii. Shave (electric) every visit iii. Make bed every visit c. The home health aide documentation dated 1/18, 1/29, 2/1, 2/2, 2/3, 2/9, 2/10, 2/15, 2/16, 2/17, 2/22, 2/23, 2/24, 2/28, 3/1, 3/2, 3/3, 3/4, 3/7, 3/8, 3/9, 3/10, 3/11, 315, 3/16, 3/18 and 3/19 revealed the patient refused nail care and shaving. Documentation dated 1/29, 2/1, 2/3, 2/9, 2/15, 2/16, 2/22, 2/23, 2/24, 3/1, 3/2, 3/3, 3/10, 3/16 and 3/18 revealed the patient refused bed making. d. During an interview on 3/29/22 at 8:10 AM Staff D, Home Care Aide identified the patient refused nail care because the podiatrist cares for the patients nails. Staff D, said the patient no longer shaves and is growing a beard and the patient refuses bed making due to spending most of the time in bed. The agency failed to individualize the aide assignment to the patient's needs. According to the undated agency policy, titled Home Health Aide Care Plan, a complete and appropriate care plan, identifying duties to be performed by the Home Health Aide, shall be developed by a Registered Nurse or Therapist. All home health aide staff will follow the identified plan. The care plan will be available to all persons involved in patient care, including contracted providers. The purpose is to provide a means of assigning duties to the Home Health Aide that are clear to the nurse, home health aide and to the patient/caregiver being served and provide documentation that the patient's care is individualized to his/her specific needs. Interview on 3/23/22 at 9:15 AM with the Clinical Manager revealed the home health aide visit note form only has documentation options of performed or refused on the form and the Clinical Manager stated "We've kinda backed ourselves into a corner". 1. Patient #1 had a start of date of 11/18/21 and received weekly skilled nursing services and two times per week home health aide services from the agency. The Plans of Care, dated 1/13/22 to 3/13/22 and 3/14/22 to 5/12/22, documented a diagnosis of Alzheimers disease. The recertification comprehensive assessments, dated 1/11/22, and 3/9/22, documented the patient was bedbound and depends entirely on someone else for grooming needs and is unable to participate effectively in bathing and is bathed totally by another person. Clinical record review and associated interviews revealed: a. The home health aide assignments for the months of January, February, and March directed the aides to perform the tasks of shampoo hair every visit, oral care every visit, assist with transfer every visit, hoyer lift every visit and instructed the home health aide to report refusal of care. b. Home health aide visit notes, dated 1/17/22, 1/20/22, 1/27/22, 1/31/22, 2/3/22, 2/7/22, 2/10/22, 2/14/22, 2/17/22, 2/21/22, 2/24/22, 2/28/22, 3/4/22, 3/7/22, 3/10/22, 3/14/22, and 3/17/22, documented the patient refused the tasks of shampoo hair, oral care, assist with transfer, and hoyer lift. The home health aide visit notes also lacked home health aide notification to the nurse of the patient's refusal of care. c. The Home Health Aide Supervisory visit notes, completed by the Registered Nurse (RN) and dated 1/25/22, 2/8/22, 2/22/22, and 3/8/22, documented the aide followed the patient's plan of care for completion of tasks as assigned and informed supervisor of patient's needs and changes in the patient's condition. During home visit observation on 3/23/22 at 11:05 AM with Staff C, Physical Therapist (PT), the surveyor spoke with patient's caregiver regarding tasks refused. The caregiver revealed the caregiver always completes the tasks of shampooing the patient's hair, performing oral care, and transfers with hoyer lift. Interview on 3/29/22 at 4:39 PM with Staff P, Home Health Aide, revealed the patient refusals were documented due to the patient's caregiver performing a lot of the assigned tasks, including shampooing hair, oral care, and assisting with transfers and hoyer lift. The aide stated no refusals were reported to the nurse as that was not how the aide was trained. The aide did receive a text from the Clinical Manager when the surveyors showed up to contact the nurse and chart what task was refused and when the task was refused. The aide assignment was not individualized to the patient's needs. 2. Patient #3 had a start of care date of 8/14/18, received skilled nursing services three times per week and home health aide services five times per week from the agency . The Plans of Care, dated 11/26/21 to 1/24/22 and 1/25/22 to 3/25/22, documented a diagnosis of a fractured femur. The recertification comprehensive assessments, dated 1/24/22, documented the patient needed to have grooming utensils placed within reach before completing grooming activities, was able to participate in bathing self in shower or tub, but required presence of another person throughout the bath for assistance or supervision, and was unable to get to and from the toilet but is able to use a bedside commode. Clinical record review and associated interviews revealed the following: a. The home health aide assignments for the months of February and March directed the aides to perform the tasks of bed bath every visit, shower with chair every visit, shampoo hair every visit, clean dentures every visit, assist with ambulation, assist with transfer every visit and report refusal of care to the nurse. The home health aide assignment did not specify when a bed bath or the shower with chair was to be performed and assigned both types of baths every visit. b. Home health aide visit notes, dated 2/9/22, 2/11/22, 2/14/22, 2/16/22, 2/17/22, 2/18/22, 2/21/22, 2/22/22, 2/23/22, 2/24/22, 2/25/22, 2/28/22, 3/1/22, , 3/2/22, 3/4/22, 3/7/22, 3/8/22, 3/9/22, 3/10/22, 3/11/22, 3/14/22, 3/15/22, 3/16/22, 3/17/22, and 3/18/22, documented the patient refused the tasks of shower with chair every visit, clean/file nails every week, every visit, and clean dentures every visit. The home health aide visit notes also lacked documentation of the home health aide notification to the nurse of the patient's refusal of care. c. The Home Health Aide Supervisory visit notes, completed by the Registered Nurse (RN) and dated 1/19/22, 2/2/22, 2/16/22, and 3/2/22, documented the aide followed the patient's plan of care for completion of tasks as assigned and informed supervisor of patient's needs and changes in the patient's condition. Interview on 3/29/22 at 7:45 AM with Staff D, Home Health Aide, revealed the patient refusals were documented due to the patient not having dentures and the patient had hip surgery recently so the patient was unable to ambulate to the shower as the patient can't walk and can barely stand. The aide stated had not been documenting notification to the nurse of the refusals, however, did send a text to notify the nurse. The aide states now has received education to complete a coordination note for refusals. The aide assignment was not individualized to the patient's needs. 3. Patient #10 had a start of care date of 1/8/21 and received weekly skilled nursing services and two times per week home health aide services from the agency in October 2021, November 2021, December 2021, January 2022, and February. The Plans of Care, dated 9/5/21 to 11/3/21, 11/4/21 to 1/2/22, and 1/3/22 to 3/3/22, documented a diagnosis of acute embolism and thrombosis. Clinical record review and associated interviews revealed: a. The home health aide assignments for the months of October, November, December, January and February, directed the aides to perform the tasks of shower with chair, shampoo hair, oral care, assist to toilet and assist with dressing every visit and documented the aide was to report refusal of care to the nurse. b. Home health aide visit notes, dated 10/29/21, 11/4/21, 11/15/21, 11/26/21, 12/2/21, 12/9/21, 12/23/21, 1/6/22, 1/20/22, 1/27/22, 2/3/22, 2/10/22, 2/18/22, 2/24/22, and 3/3/22, documented the patient refused the tasks of shower with chair, shampoo hair, oral care, assist to toilet and assist with dressing every visit. The home health aide visit notes also lacked home health aide notification to the nurse of the patient's refusal of care. Interview on 3/30/22 at 4:39 PM with Staff Q, Home Health Aide, revealed the patient was always refusing the cares of assist with transfers, shampoo hair and oral care as the patient was capable of performing those tasks independently. The aide did report the refusals to the nurse, but did not document these at the time and all communications were done via text messaging. Interview with Staff B, RN, revealed the nurse was told by the aide of patient refusing care and recently discontinued home health aide services. The aide assignment was not individualized to the patient's needs.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 6 of 8 sampled patients receiving home health aide services (Patients #1, #3, #6, #7, #8 and #10). The agency reported 74 patients currently received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: 4. Patient #6 had a start of care date of 6/13/2019. Clinical record review and associated interviews revealed the following: The Plans of Care, dated 11/29/2021 to 1/27/2022 and 1/28/2022 to 3/28/2022, included physician orders for home health aide services 5 times weekly to assist with" personal care and activities of daily living as indicated by limitations on functional and physical status impeding self-care." The physician's interim order, dated 2/14/2022, decreased home health aide visits to 3 times weekly for the rest of the certification period. a. The Home Health Aide Care Plans, dated 11/24/2021 and 1/26/2022, directed the aide to provide a shower, shampoo, dressing assistance, apply lotion, comb hair, provide oral care, shave with an electric razor and clean/file the patient's nails. All of the tasks were assigned completed every visit. The Care plans also directed the home health aide to report any refusal of task to the patient's RN/case manager. b. The Home Health Aide Visit notes revealed the patient refused the following: shower- 1/17,18,19,20,21,24,28,31/2022; 2/1,3,4,8,11,14,17,18,23,24,28/2022; 3/17,18/2022 comb hair- 1/17,18,19,20,21,24,28,31 /2022; 2/1,3,4,8,11,14,18/2022 shampoo- 1/17,18,19,20,21,24,28,31 /2022; 2/1,3,4,8,11,14,17,18,23,24,28/2022; 3/17,18/2022 oral care- 1/17,18,19,20,21,24,28,31 /2022; 2/1,3,4,7,8,11,14,17,18,23,28/2022; 3/17,18/2022 clean/file nails- 1/17,18,19,20,21,24,28,31 /2022; 2/1,3,4,7,8,11,14,23/2022; 3/17,18/2022 shave- 1/17,18,19,20,21,24,28,31 /2022; 2/1,3,4,7,8,11,14,17,18,23,24,28/2022; 3/17,18/2022 None of the above stated visit notes documented the aide reported the refused tasks to the RN. The clinical record lacked any communication note or other document indicating the aide had reported the refused tasks as assigned to do. c. During patient interview on 3/24/2022 at 2:40 PM, Patient #6 reported having the ability to shaving independently. The patient reported having no teeth or dentures so did not require oral care assistance, was independent with nail care and preferred to take a shower and shampoo at night. Patient #6 reported his/her adult child assisted with shower and shampoo in the evenings but not every day as the patient did not shower/shampoo every day. The patient reported the home health aides rarely assisted with shower/shampoo. d. The Home Health Aide Supervisory Visit notes, dated 1/17/2022, 1/31/2022, 2/14/2022, 2/28/2022 and 3/14/2022, each documented the aide was following the patient's RN assigned care plan, informed the supervisor of the patient's needs and changes as required and had no need to change the care plan tasks. 5. Patient #7 had a start of care date of 10/25/2021 and was discharged from agency services on 12/20/2021. Clinical record review and associated interviews revealed the following: The Plan of Care, dated 10/25/2021 to 12/23/2021, included physician orders for home health aide services 5 times weekly to assist with" personal care and activities of daily living as indicated by limitations on functional and physical status impeding self-care." a. The Home Health Aide Care Plan, dated 10/30/2021, directed the aide to provide a shower using a chair, shampoo, dressing assistance, apply lotion, comb hair, provide oral care, clean dentures, shave with an electric razor, clean/file the patient's nails and assist to the toilet/provide incontinence care. All of the tasks were assigned completed every visit. b. The Home Health Aide Visit notes revealed the patient refused the following:shower- 11/8,16,18,30/2021; 12/7,16/2021 dressing- 11/8,16,18,30/2021;12/7,16/2021 lotion- 11/8,16,18,30/2021; 12/7,16/2021 comb hair- 11/8,16,18,30/2021; 12/7,16/2021 shampoo- 11/8,16,18,30/2021; 12/7,16/2021 oral care- 11/8,16,18,29,30/2021; 12/1,7,14,16/2021 clean dentures- 11/8,12,15,16,18,22,29,30/2021; 12/1,6,7,14,16/2021 clean/file nails- 11/8,12,15,16,18,29,30/2021; 12/1,6,7,8,14,15,16/2021 shave- 11/8,9,10,12,15,16,18,22,29,30/2021; 12/1, 6,7,8,13,14,15,16/2021 None of the above stated visit notes documented the aide reported the refused tasks to the RN. The clinical record lacked any communication note or other document indicating the aide had reported the refused tasks as assigned to do. c. During patient caregiver interview on 3/24/2022 at 12:30 PM, Patient #7's sibling reported performing the following tasks routinely for the patient: shaving, combing hair, cleaning out the patient's mouth with swabs as he/she had no teeth and did not wear dentures and nail care. Patient #7's sibling reported residing with the patient and observed care provided to the patient by the home health aides. "The girls did shower, shampoo apply lotion to the body/Vaseline to the feet and helped with dressing." d. The Home Health Aide Supervisory Visit notes, dated 10/27/2021, 11/10/2021, 11/24/2021, 12/6/2021 and 12/20/2021, each documented the aide was following the patient's RN assigned care plan, informed the supervisor of the patient's needs and changes as required and had no need to change the care plan tasks. 6. Patient #8 had a start of care date of 8/17/2017. Clinical record review and associated interviews revealed the following: The Plan of Care, dated 1/23/2022 to 3/23/2022, included physician orders for home health aide services 4-5 times weekly to assist with" personal care and activities of daily living as indicated by limitations on functional and physical status impeding self-care." The physician's interim order, dated 2/14/2022, decreased home health aide visits to 3 times weekly for the rest of the certification period. a. The Home Health Aide Care Plans, dated 1/21/2022 and 1/27/2022, directed the aide to provide a bed bath, shampoo, dressing assistance, apply lotion, comb hair, provide oral care and clean/file the patient's nails. All of the tasks were assigned completed every visit. b. The Home Health Aide Visit notes revealed the patient refused the following:comb hair- 3/10/2022 shampoo- 2/8,22/2022; 3/2,8,10/2022 oral care- 1/31/2022; 2/3,7,8,9,22/2022; 3/2,8,10/2022 clean/file nails- 2/9,21,24/2022; 3/8/2022 None of the above stated visit notes documented the aide reported the refused tasks to the RN. The clinical record lacked any communication note or other document indicating the aide had reported the refused tasks as assigned to do. c. During patient caregiver interview on 3/28/2022 at 8:30 PM, Patient #8's parent reported the aides routinely perform a bed bath every visit, shampoo every other day, dress the patient in a shirt and incontinence brief and change the incontinence pad on the bed. Patient #8's parent reports routinely providing oral care to the patient and the nurse/podiatrist trim the patient's nails as the patient is diabetic. d. The Home Health Aide Supervisory Visit notes, dated 1/24/2022, 2/7/2022, 2/21/2022 and 3/21/2022, each documented the aide was following the patient's RN assigned care plan, informed the supervisor of the patient's needs and changes as required and had no need to change the care plan tasks. The surveyors reviewed the above stated findings for Patients #1, #3, #6, #7, #8 and #10 with the Administrator, the Clinical Manager and Staff A, Office Admin. The agency provided no additional information prior to the end of the survey. According to the undated agency policy, titled Home Health Aide Care Plan, a complete and appropriate care plan, identifying duties to be performed by the Home Health Aide, shall be developed by a Registered Nurse or Therapist. All home health aide staff will follow the identified plan. The care plan will be available to all persons involved in patient care, including contracted providers. The purpose is to provide a means of assigning duties to the Home Health Aide that are clear to the nurse, home health aide and to the patient/caregiver being served and provide documentation that the patient's care is individualized to his/her specific needs. Interview on 3/23/22 at 9:15 AM with the Clinical Manager revealed the home health aide visit note form only has documentation options of performed or refused on the form and the Clinical Manager stated "We've kinda backed ourselves into a corner". 1. Patient #1 had a start of date of 11/18/21 and the Plans of Care, dated 1/13/22 to 3/13/22 and 3/14/22 to 5/12/22 included orders for weekly skilled nursing services and two times per week home health aide services from the agency to provide assistance with personal cares and activities of daily living as indicated by limitations on functions and physical status impeding self care. Clinical record review revealed: a. The home health aide assignments for the months of January, February, and March directed the aides to perform the task hoyer lift every visit. The Plans of Care, lacked a physician's order for the hoyer lift transfers assigned as an extension of nursing services to the aide. b. Home health aide visit notes, dated 1/17/22, 1/20/22, 1/27/22, 1/31/22, 2/3/22, 2/7/22, 2/10/22, 2/14/22, 2/17/22, 2/21/22, 2/24/22, 2/28/22, 3/4/22, 3/7/22, 3/10/22, 3/14/22, and 3/17/22, documented the patient refused the tasks of shampoo hair, oral care, assist with transfer, and hoyer lift. The home health aide visit notes also lacked home health aide notification to the nurse of the patient's refusal of care. c. The Home Health Aide Supervisory visit notes, completed by the Registered Nurse (RN) and dated 1/25/22, 2/8/22, 2/22/22, and 3/8/22, documented the aide followed the patient's plan of care for completion of tasks as assigned and informed supervisor of patient's needs and changes in the patient's condition. During home visit observation on 3/23/22 at 11:05 AM with Staff C, Physical Therapist (PT), the surveyor spoke with patient's caregiver regarding tasks refused. The caregiver revealed the caregiver always completes the tasks of shampooing the patient's hair, performing oral care, and transfers with hoyer lift. Interview on 3/29/22 at 4:39 PM with Staff P, Home Health Aide, revealed the patient refusals were documented due to the patient's caregiver performing a lot of the assigned tasks, including shampooing hair, oral care, and assisting with transfers and hoyer lift. The aide stated no refusals were reported to the nurse as that was not how the aide was trained. The aide did receive a text from the Clinical Manager when the surveyors showed up to contact the nurse and chart what task was refused and when the task was refused. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. 2. Patient #3 had a start of care date of 8/14/18. The Plans of Care dated, 11/26/21 to 1/24/22 and 1/25/22 to 3/25/22 included order for skilled nursing services three times per week and home health aide services five times per week from the agency to provide assistance with personal cares and activities of daily living as indicated by limitations on functions and physical status impeding self care. Clinical record review and associated interviews revealed the following: a. The home health aide assignments for the months of January, February and March directed the aides to perform the tasks of applying over the counter lotion per patient request to bilateral lower extremities followed by compression stockings, bed bath every visit, shower with chair every visit, shampoo hair every visit, clean dentures every visit, assist with ambulation, assist with transfer every visit and report refusal of care to the nurse. The home health aide assignment did not specify when a bed bath or the shower with chair was to be performed and assigned both types of baths every visit. The Plans of Care lacked identification of compression stockings to be applied by the aide assigned as an extension of nursing services to the aide. b. Home health aide visit notes, dated 2/9/22, 2/11/22, 2/14/22, 2/16/22, 2/17/22, 2/18/22, 2/21/22, 2/22/22, 2/23/22, 2/24/22, 2/25/22, 2/28/22, 3/1/22, , 3/2/22, 3/4/22, 3/7/22, 3/8/22, 3/9/22, 3/10/22, 3/11/22, 3/14/22, 3/15/22, 3/16/22, 3/17/22, and 3/18/22, documented the patient refused the tasks of shower with chair every visit, clean/file nails every week, every visit, and clean dentures every visit. The home health aide visit notes also lacked documentation of the home health aide notification to the nurse of the patient's refusal of care. c. The Home Health Aide Supervisory visit notes, completed by the Registered Nurse (RN) and dated 1/19/22, 2/2/22, 2/16/22, and 3/2/22, documented the aide followed the patient's plan of care for completion of tasks as assigned and informed supervisor of patient's needs and changes in the patient's condition. Interview on 3/29/22 at 7:45 AM with Staff D, Home Health Aide, revealed the patient refusals were documented due to the patient not having dentures and the patient had hip surgery recently so the patient was unable to ambulate to the shower as the patient can't walk and can barely stand. The aide stated had not been documenting notification to the nurse of the refusals, however, did send a text to notify the nurse. The aide states now has received education to complete a coordination note for refusals. The aide revealed has been helping the patient apply compression stockings. The home health aide visit note lacked documentation of performance of the task of applying compression stockings. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. 3. Patient #10 had a start of care date of 1/8/21 and The Plans of care, dated 9/5/21 to 11/3/21, 11/4/21 to 1/2/22, and 1/3/22 to 3/3/22, ordered weekly skilled nursing services and two times per week home health aide services from the agency to provide assistance with personal cares and activities of daily living as indicated by limitations on functions and physical status impeding self care Clinical record review and associated interviews revealed: a. The home health aide assignments for the months of October 2021, November 2021, December 2021, January 2022 and February 2022, directed the aides to perform the tasks of shower with chair, shampoo hair, oral care, assist to toilet and assist with dressing every visit and documented the aide was to report refusal of care to the nurse. b. Home health aide visit notes, dated 10/29/21, 11/4/21, 11/15/21, 11/26/21, 12/2/21, 12/9/21, 12/23/21, 1/6/22, 1/20/22, 1/27/22, 2/3/22, 2/10/22, 2/18/22, 2/24/22, and 3/3/22, documented the patient refused the tasks of shower with chair, shampoo hair, oral care, assist to toilet and assist with dressing every visit. The home health aide visit notes also lacked home health aide notification to the nurse of the patient's refusal of care. Interview on 3/30/22 at 4:39 PM with Staff Q, Home Health Aide, revealed the patient was always refusing the cares of assist with transfers, shampoo hair and oral care as the patient was capable of performing those tasks independently. The aide did report the refusals to the nurse, but did not document these at the time and all communications were done via text messaging. Interview with Staff B, RN, revealed the nurse was told by the aide of patient refusing care and recently discontinued home health aide services. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on review of criminal background checks, child abuse and dependent adult abuse record checks, the agency allowed 2 of 4 sampled employees hired or contracted after 7/1/2022 without completing the required criminal history, dependent adult abuse and child abuse background checks prior to hire (Staff F and the Clinical Manager). The agency hired 9 new employees since 7/1/2022. The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and supported the adherence to state regulations and coordination of safe and effective delivery of care to the agency's 138 patients. 481 IAC (Iowa Administrative Code) rule 50.9 requires Home Health Agencies complete a criminal background history check, a dependent adult abuse background history check and a child abuse background history check on each prospective employee who will have direct patient contact. The home health agency must complete these record checks prior to the date of hire of a prospective employee. If a positive criminal history, dependent adult abuse history or child abuse history is identified, the agency must seek approval to hire from the Department of Human Services. Failure to complete the required backgrounds checks according to the State of Iowa requirements placed agency patients at risk for potential harm. Findings include: a. Staff F, Registered Nurse (RN), had a hire date of 9/7/2021. Staff F, RN's, personnel file included an initial criminal history check, dependent adult abuse history check and child abuse history check, completed on 9/7/2021. The criminal history background check was marked "further research is required. Please await DCI's final response for criminal history." but found no dependent adult abuse or child abuse history. Staff F, RN's, personnel file lacked documentation of any final results from DCI; therefore, the criminal history check was not completed. The agency hired Staff F, RN, prior to completion of the criminal history check. b. The Clinical Manager had a hire date of 7/9/2021. The Clinical Manager's personnel file included an initial criminal history check, dependent adult abuse history check and child abuse history check, completed on 7/8/2021. The criminal history background check was marked "further research is required. Please await DCI's final response for criminal history." but found no dependent adult abuse or child abuse history. The Clinical Manager's personnel file lacked documentation of any final results from DCI; therefore, the criminal history check was not completed. The agency hired the Clinical Manager prior to completion of the criminal history check. The above stated findings were reviewed with the Clinical Manager. The Clinical Manager went into the SING site and was unable to pull up the previous background results. The Clinical Manager immediately requested another background check for both herself and Staff F, RN, and was awaiting the results upon exit. No further information was provided by the agency prior to the end of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency was found operating out of compliance with with the requirements of this Condition of Participation for the following reasons: 1) the agency failed to ensure agency staff completed routine visit documentation according to administrative expectations (G1024); 2) the agency failed to ensure agency staff dated documentation the day of occurrence without backdating documentation (G1024); and 3) the agency failed to maintain all patient care documentation for a minimum of 5 years as required by federal/state guidance and the agency's own policy (G1026). The systemic practice resulted in the failure to ensure the organization framework of the agency promoted and protected the rights of the agency's 139 patients.

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 clinical record review and agency staff interview, the agency failed to ensure documentation of routine visit notes were completed within the agency's administrative expectations and/or were dated as date documented for 6 of 9 sampled patients (Patients #1, #3, #4, #6, #7 and #8). Failure to maintain appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: 5. Patient #3 had a start of care date of 8/14/2018. Clinical record review revealed the following: a. The electronic home health aide visit note, dated 1/18/22, was not electronically signed as complete until 1/23/22, making the completion of the document 4 days late. b. The electronic home health aide visit note, dated 1/19/22, was not electronically signed as complete until 1/23/22, making the completion of the document 3 days late. c. The electronic home health aide visit note, dated 1/20/22, was not electronically signed as complete until 1/23/22, making the completion of the document 2 days late. d. The electronic home health aide visit note, dated 1/21/22, was not electronically signed as complete until 1/25/22, making the completion of the document 3 days late. e. The electronic home health aide visit note, dated 1/31/22, was not electronically signed as complete until 2/6/22, making the completion of the document 5 days late. f. The electronic home health aide visit note, dated 2/2/22, was not electronically signed as complete until 2/6/22, making the completion of the document 3 days late. g. The electronic home health aide visit note, dated 3/15/22, was not electronically signed as complete until 3/21/22, making the completion of the document 5 days late. 6. Patient #1 had a start of care date of 1/18/2021. Clinical record review revealed the electronic home care aide visit note, dated 3/10/21, was not electronically signed as complete until 3/14/21 making the completion of the document 3 days late. The surveyors reviewed the above findings for Patients #1, #3, #4, #6, #7, and #8 with agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey. 4. Patient #4 had a start of care date of 7/01/21. Review of the clinical record revealed the following: a. The Home Health Aide visit note, dated 1/18/22, documented a signature per the electronic event log 1/23/22, 4 days late. b. The Home Health Aide visit note, dated 1/19/22, documented a signature per the electronic event log 1/23/22, 3 days late. c. The Home Health Aide visit note, dated 1/20/22, documented a signature per the electronic event log 1/23/22, 2 days late. d. The Home Health Aide visit note, dated 2/28/22, documented a signature per the electronic event log 3/2/22, 1 day late. e. The Home Health Aide visit note, dated 2/2/22, documented a signature per the electronic event log 2/6/22, 3 days late. f. The Home Health Aide visit note, dated 3/7/22, documented a signature per the electronic event log 3/9/22, 1 day late. g. The Home Health Aide visit note, dated 3/11/22, documented a signature per the electronic event log 3/14/22, 2 days late. h. The Home Health Aide visit note, dated 3/14/22, documented a signature per the electronic event log 3/21/22, 6 days late. During agency staff entrance interviews on 3/21/2022 at 10:40 AM, the Clinical Manager reported her expectation that all nursing and home health aide routine visit notes be completed within 24 hours of the visit date. 1. Patient #7 had a start of care date of 10/25/2021 and was discharged from agency services on 12/20/2021. Clinical record review and associated staff interviews revealed the following: a. The clinical record included: A communication note, dated 12/20/2021. The communication note, dated 12/20/2021 and completed by the Clinical Manager, documented the home health aide reported to the registered nurse the patient was being taken to the emergency room via primary caregiver on "this date". The communication note, dated 12/20/2021 and completed by Staff N, previous office manager, indicating the agency was notified on 12/21/2022 that the patient was admitted observation status at the local hospital with diagnosis of worsening kidney function. The note was dated one day before the agency was notified of the admission. The physician order, dated 12/20/2021 and signed by the Administrator on 12/20/2021, included discharge orders due to the patient's admission into the hospital. The physician's order was completed by the Administrator one day before the agency was notified of patient's admission. The Transfer Discharge OASIS (Outcome and Assessment Information Set), dated 12/20/2021 and completed by the Clinical Manager one day before the agency became aware of the patient's admission to the hospital, was not created until 12/21/2021 and electronically signed on 12/21/2021. On 3/22/2022 at 9:30 AM, the surveyor asked the Clinical Manager to review Patient #7's electronic clinical record with the surveyor due to the above stated discrepancies. During agency staff interview on 3/22/2022 at 9:45 AM, the Clinical Manager reported she noted the patient went to the emergency room on 12/20/2021 and was admitted to the hospital in observation status on 12/20/2021. Nurse At Home was notified on 12/21/2021 of the admission. The communication note and the Transfer to Inpatient Facility Discharge OASIS were backdated to reflect a date prior to the transfer for billing purposes as the Administrator reports this is necessary. b. The electronic routine home health aide visit note, dated 11/9/2021, was not electronically signed as complete until 11/17/2021, making the completion of the document 7 days late according to administrative expectation. c. The electronic routine home health aide visit note, dated 11/10/2021, was not electronically signed as complete until 11/24/2021, making the completion of the document 13 days late according to the administrative expectation. 2. Patient #6 had a start of care date of 6/13/2022. Clinical record review revealed the following: a. The electronic routine home health aide visit note, dated 1/21/2022, was not electronically signed as complete until 1/24/2022, making the completion of the document 2 days late according to administrative expectation. b. The electronic routine home health aide visit note, dated 2/23/2022, was not electronically signed as complete until 2/25/2022, making the completion of the document 1 day late according to the administrative expectation. 3. Patient #8 had a start of care date of 8/17/2017. Clinical record review revealed the following: a. The electronic routine home health aide visit note, dated 1/26/2022, was not electronically signed as complete until 2/3/2022, making the completion of the document 6 days late according to administrative expectation. b. The electronic routine home health aide visit note, dated 3/15/2022, was not electronically signed as complete until 3/17/2022, making the completion of the document 1 day late according to the administrative expectation.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to maintain documentation completed in the agency's electronic medical record system for 5 years after the patient's discharge from services for 1 of 9 sampled patients (Patient #7). Failure to maintain documentation for the required timeframe prevented patients from access to a full clinical record review if requested. Findings include: According to the undated agency policy, titled Medical Record Information Retention and Destruction, to ensure medical record information retention and destruction is in accordance with federal and state laws and regulations, the agency will maintain all adult medical record for a minimum of five years after discharge of the patient. Patient #7 had a start of care date of 10/25/2021 and was discharged from agency services on 12/20/2021. Clinical record review and associated staff interviews revealed the following: a. The clinical record included: Communication notes, dated 12/20/2021, documented the home health aide reported to the registered nurse the patient was being taken to the emergency room via primary caregiver and the patient was subsequently admitted observation status at the local hospital with diagnosis of worsening kidney function. (See G1024 for additional information) The Transfer Discharge OASIS (Outcome and Assessment Information Set), dated 12/20/2021 and completed by the Clinical Manager one day before the agency became aware of the patient's admission to the hospital, was not created until 12/21/2021 and electronically signed on 12/21/2021. On 3/22/2022 at 9:30 AM, the surveyor asked the Clinical Manager to review Patient #7's electronic clinical record with the surveyor due to the above stated discrepancies. During agency staff interview on 3/22/2022 at 9:30 AM, the Clinical Manager reported she had made a skilled nurse visit on 12/20/2021, noted changes in the patient's status, set up the emergency room transfer and stayed with the patient and primary caregiver until taken by ambulance to the emergency room. The Clinical Manager reviewed the electronic record and was unable to find her documentation from the 12/20/2021 skilled nurse visit. She reported the note "appears deleted, I know I was there for the visit." During agency staff interview on 3/22/2022 at 9:45 AM, the Clinical Manager reported she further reviewed the above stated information, noting the patient went to the emergency room on 12/20/2021 and was admitted to the hospital in observation status on 12/20/2021. Nurse At Home was notified on 12/21/2021 of the admission. The communication note and the Transfer to Inpatient Facility Discharge OASIS were backdated to reflect a date prior to the transfer for billing purposes as the Administrator reports this is necessary. She believes her skilled nurse visit note was deleted from the agency's electronic record keeping system due to the need to backdate the communication note and the OASIS. The note no longer existed within the electronic system and could not be retrieved. The above stated findings were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

The Department conducted an investigation of complaint #98118-C, conducted 7/12/2021 through 7/14/2021. The complaint investigation identified the following: Allegations related to 42 CFR 484.50 Patient Rights were substantiated with related condition level deficiencies identified (See G402, G438, G460, G462, G464, G466 and G468); Allegations related to 42 CFR 484.60 Care Planning, Coordination and Quality of Care were unsubstantiated; The complaint investigation was extended due to the agency's non-compliance at a condition level as stated above. The extended complaint investigation identified additional condition level deficiencies unrelated to the complaint allegations at: 42 CFR 484.55 Comprehensive Assessment of Patients (See G510, G520, G528, G546, G548 and G550) and 42.CFR 484.105 Organization and Adminstration of Services (See G960 and G964) The extended complaint investigation also identified additional standard level deficiencies unrelated to the complaint allegations (See G572, G590, G724, G800, G960, G964 and G1022). As a result of the agency's continued non-compliance with federal Conditions of Participation following the 7/12-14/2021 condition level complaint investigation, the previously imposed two year prohibition due to past condition level surveys was extended. The agency and its registered nurses are now prohibited from providing basic home health aide skills competency training and from providing both written and demonstrated basic skills competency evaluation for all newly hired home health aides for a period of 2 years, commencing on 7/14/2021 and ending on 7/14/2023.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, review of additional applicable documents, agency staff interview and patient/caregiver interview, the agency failed to do the following: 1) ensure patients had the right to request access to their own home health medical record (G438); 2) ensure agency staff documented communication with the physician patient's request for discharge due to refusal of ordered skilled services, measures taken to investigate the reason for the refusal and what interventions were attempted to obtain patient participation in the refusal of skilled services (G460); 3) ensure agency staff advised the patient and physician the agency was considering cause for discharge (G464); 4) ensure agency staff made efforts to resolve the problem before discharging (G466); and 5) ensure agency staff provided contact information for other resources and providers at discharge for cause (G468). The systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 128 patients.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, review of other applicable documents, agency staff interview and patient/caregiver interview, the agency failed to honor patient rights to access to their own home health medical record for 1 of 1 sampled patients who wished to review/receive copies of the medical record (Patient #3). The agency reported a current census of 128 patients. The agency reported discharging 34 patients between 4/1/2021 and 7/12/2021. Failure to allow patients access to their own medical records resulted in violation of the patient's rights as allowed by agency policy, home health regulation and governing laws. Findings include: According to the undated agency policy, titled Patient Bill of Rights and Responsibilities, agency staff will be responsible for knowing, observing and implementing the patient's rights and responsibilities on an ongoing basis. The Patient Bill of Rights and Responsibilities will be given to each patient at the time of the initial assessment and prior to admission. According to the undated Client (patient) Bill of Rights, the patient has the right to the following: Be informed of his or her rights; Exercise the rights at any time; Voice and report grievances or complaints regarding treatment or care that are delivered or failed to be delivered or any violation of any rights to the agency, state or local agencies; Participate in, be informed about and consent to or refuse care in advance of and during treatment; Receive all service in the plan of care; Receive proper written notice if the home health agency is reducing or terminating ongoing care; and Have a confidential patient record and access to or release of patient information and records in accordance with Health Insurance Portability and Accountability Act (HIPAA) law and regulation. 1. Patient #3 had a start of care date of 2/1/2021 and was discharged by the agency for cause on 4/20/2021. a. Clinical record review included the following: The Plans of Care, dated 2/1/2021 to 4/1/2021 and 4/2/2021 to 5/31/2021, included physician orders for skilled nurse visits twice weekly to reconcile medications and instruct/educate/reinforce teaching related to the use of medications. Skilled nurse visit note, dated 4/19/2021 by Staff F, Licensed Practical Nurse (LPN), documented the patient misunderstood something the nurse said involving personal information shared with the patient's physician. The patient reportedly "blew up, making phone calls, stating (patient) was going to sue someone, yelling and screaming. This nurse excused herself and promptly left." The Communication Note, dated 4/20/2021, by Staff A, Administrative Assistant, reporting Patient #3's Amerigroup case manager contacted the agency to discuss the patient's behavior during the home visit the day before (4/19/2021). The Amerigroup case manager reported Patient #3 was disgruntled the previous day, had contacted the sheriff's office and they made a visit to the patient's home. The patient "seemed to have calmed down by the time officials arrived. The note documented the Amerigroup case manager "concurred the agency should discharge patient from services due to patient's behavior with staff in the home." The update to the comprehensive assessment at the time of discharge, dated 4/20/2021, documented the patient requested to be discharged from agency services. The discharge summary, dated 4/20/2021, documented the agency discharged the patient at the request of the patient. The physician's order, dated 4/20/2021 by the agency Administrator, stated "please discharge patient from Nurse At Home, Home Healthcare per patient request." b. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported receiving home health services from the agency in the past approximate 2 years. The patient report a nurse visited twice weekly since admission, administering an androgen replacement injection during one of the visits every other week until mid April. The physician stopped approving the prescription for the androgen replacement medication in mid April and the nurse was unable to give the injection. The patient reported, during the last visit made by the nurse, the nurse told him/her she couldn't give me the injections anymore because Staff G, Registered Nurse (RN), shared some personal information with the physician, causing the physician to stop prescribing the medication. The patient reported the shared information was untrue and admitted to becoming very upset, yelling and threatening to sue. The patient reported, the agency just stopped coming to see me. The patient reported calling the agency multiple times but always getting voice mail so he/she left a message in attempt to find out why they were no longer coming and obtain information from his/her chart. The patient reported no return call was received from any representative of the agency. On June 3, 2021 the patient went to the home health office. Upon entering, he/she was met by Staff A, Administrative Assistant. "She told me I was no longer a patient, then when I asked for information from my chart, she told me I had no right to it as I was no longer a patient. The patient reported he/she asked the Administrative Assistant again for printed copies of my chart and she refused- told me to leave or she would call the cops. I left and the administrative assistive still called the cops. They visited me and told me I can't go there anymore." "I then sent a certified letter requesting copies of my medical record and they refused to accept the letter on delivery." "I asked for information for a lawyer for Nurse At Home when I was in the office and the Administrative Assistant told me they don't have one." The patient reported never speaking to any other agency staff except Staff A, Administrative Assistant about the concerns or requests. The patient denies attempting any further contact by phone, email or in person since 6/3/2021. No one from the agency had contacted Patient #3 since the office visit. The patient denied requesting discharge or ever receiving any discharge paperwork from the agency. The patient did report sending a written request for access to his/her medical records by certified mail. The patient gave to the surveyor, a copy of the letter sent to the agency in the certified letter and a picture of the unopened, undelivered envelope with the original certified letter request inside. The unopened envelope was addressed to the proper address for Nurse At Home business and documented the letter was originally postmarked as sent on 6/9/2021, refused by the agency on 6/11/2021, was marked by the post office "return to sender- refused- unable to forward." on 6/16/2021 and marked returned on 7/3/2021. The copy of the letter sent to agency was dated June 9, 2021, was addressed to Nurse At Home and stated in part "To whom it may concern, In order to obtain my medical records regarding services provided to me by Nurse At Home, a phone message requesting them was left at (correct telephone number of the agency) sometime in May of 2021. Since no response was received, a personal visit to (correct address of the home health agency) occurred on 6/3/2021. During the brief visit, (Staff A, Administrative Assistant) was very rude with me. She informed me that she would not provide my medical records- claiming that she did not have to since I was no longer a client with Nurse At Home. I then asked for contact information for the attorney representing Nurse At Home and she stated that Nurse At Home did not have an attorney. She then asked me to leave the business and I did. She then reported me to law enforcement- falsely claiming that I was harassing her. Consultations with my caseworker, psychiatrist (and others) informed me that Nurse At Home is obligated to provide me with my medical records- regardless of my not currently being a patient with them. I also discovered that the release of my records is also mandated through Individuals' Rights under HIPAA to Access their Health Information 45 CFR 164.524.......This is my written request for all of the documentation showing the services provided to me, the dates on which these services were provided and the names of the staff members who provided them....... Please send all of my records by mail or email to the address below. I will also need you to provide me with a complaint/grievance form. Filing one is the initial step required in taking legal action against Nurse At Home........" c. Review of the police report, dated 6/3/2021, documented a call was received from Nurse At Home alleging Patient #3 had "been calling harassing them, also leaving nasty Facebook messages, stopped in the office randomly and staff were a bit intimidated by (the patient)". The report indicated the patient was visited and "told not to return to the premises (of Nurse At Home) or would be charged with trespass." (The agency did not provide any documentation of telephone or Facebook harassment during the survey.) d. During agency staff interview on 7/14/2021 at 12:30 PM, Staff F, LPN, reported she did routinely see Patient #3 twice weekly and gave androgen replacement injections every other week. On 4/19/2021 the LPN saw Patient #3 in the patient's home. The patient asked the nurse why the physician stopped providing a prescription for the androgen replacement medication. The LPN reported telling the patient some personal information was told to the physician that made the physician stop prescribing it. The patient got "angry and asked who told him that? I told him (Staff G, Registered Nurse (RN)) did and (the patient) started yelling- telling me (the patient) needed her last name because (the patient) was going to sue her. (The patient) got on the phone and was trying to make a call. (The patient) never threatened me at all. I just left because (the patient) was upset. I went to the home health office and told (Staff A, Administrative Assistant) about (the patient) getting upset and what happened. I told her I wasn't sure I wanted to see (the patient) if (the patient's) temper was so explosive. She said no one else wanted to see (the patient) either. So (the patient) was discharged after that and I never went back." e. During agency staff interview on 7/14/2021 at 3:10 PM, Staff A, Administrative Assistant reported Patient #3 did make many calls after discharge but did not ever request copies of the home health medical record. The Administrative Assistant reported the patient came into the office unannounced, the patient requested a list of all employees and she refused. Patient #3 asked to talk with the agency's lawyer so he was told to leave because he was no longer a patient or she would call the police. "Maybe I misunderstood what (the patient) was asking for." The Administrative Assistant verified the patient did leave but called the police to file a report anyway because she felt intimidated because of the patient's size and the patient "talks fast." She did verify she refused the certified letter delivery because the postal worker told her the patient may be able to get her last name if she signed the delivery receipt and she did not want the patient to have her name. Staff A, Administrative Assistant, reported there was no other documentation about this incident to provide to the surveyor. The above findings for Patient #3 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to document communication with the physician to discuss patient refusal of skilled services, failed to document any measures taken to investigate the reason for refusal of the skilled services and failed to document interventions/education attempted in order to obtain the patient's participation with the physician ordered Plan of Care when discharging a patient at the request of the patient for 1 of 1 sampled patients discharged per patient request (Patient #2). The agency reported a current census of 128 patients. The agency reported discharging 34 patients between 4/1/2021 and 7/12/2021. Failure to investigate/educate/intervene and communicate with the physician to address a patient's request to be discharged due from physician ordered skilled services places patients at risk for inadequate medical care and increased safety risk due to lack of medical oversight. Findings include: According to the undated agency policy, titled Patient Bill of Rights and Responsibilities, agency staff will be responsible for knowing, observing and implementing the patient's rights and responsibilities on an ongoing basis. The Patient Bill of Rights and Responsibilities will be given to each patient at the time of the initial assessment and prior to admission. According to the undated Client (patient) Bill of Rights, the patient has the right to the following: Be informed of his or her rights; Exercise the rights at any time; Participate in, be informed about and consent to or refuse care in advance of and during treatment; Receive all service in the plan of care; and Receive proper written notice if the home health agency is reducing or terminating ongoing care. According to the undated agency policy, titled Patient Transfer/Agency Dissolution, the agency will initiate patient transfer and discharge when: The agency must dissolve and no longer in business; The agency is no longer capable of providing care needed; When one or more elements of the discharge criteria is met and another organization is appropriate to assume care. The need for discharge will be confirmed and the physician will be notified. The agency will speak with the patient by telephone or in person to at least 5 days before the date of discharge. The agency will document in the patient's chart that the patient's attending physician was notified of the discharge. According to the undated agency policy, titled Criteria for Patient Admission and Discharge, patient's requesting discharge do not require prior 5 day notification. According to the undated agency policy, titled Patient Discharge, agency staff will confirm the need for discharge and identify any remaining discharge planning needs. Staff will notify the physician of the need to discharge and obtain a discharge order. Staff will speak with the patient by telephone or in person 5 days before the date of discharge to ensure the patient's knowledge of the discharge; however, if the patient requests discharge, the patient does not need 5 days notice. Each patient will be educated on aspects of post-discharge continuity of care arrangements. Medical record documentation for discharge includes the following: Progress toward goals/ discharge summary, Discharge Comprehensive Assessment, Discharge orders. Agency will have the patient or authorized representative complete and sign a generic notice. Patient or authorized representative should sign and date. Telephone or email contact may substitute for an in person visit to deliver notice and both require follow up with a written generic notice. A dated copy of the generic notice will be placed in the patient's medical file and is to include the name of person initiating contact, name of representative contacted, dated and time of contact and the telephone number. Agency will retain a copy and completed copies will be sent to the patient or authorized representative.Patient #2 had a start of care date of 12/9/2020 and discharged from agency services on 6/23/21. Clinical record review revealed: a. The Plans of Care (POCs), dated 12/9/2020 to 2/6/21, 2/7/21 to 4/7/21, 4/8/21 to 6/6/21, and 6/7/21 to 8/5/21, included physician orders for skilled nursing and home health aide services. The POCs included orders for the skilled nurse to do a complete physical assessment every visit with focus on diabetes mellitus. b. A generic discharge form stated the agency "strives to provide the highest quality home health services. We plan an prepare for each of our patient's discharges. This letter is to notify you of discharge from our home care services effective ________(place for a date). The decision has been made to discharge you from home care services for the following reason(s)..... refuses to accept home care services." The entire form was left blank and was signed and dated on admission, 12/9/2020. c. The update to the comprehensive assessment completed at discharge by the Administrator/Clinical Manager, dated 6/23/21, included documentation the patient's physician and the patient were in agreement to discharge the patient due to the patient's refusal of services. The discharge assessment also documented the agency was discharging the patient per request, information was provided to the patient on self-management of disease, patient is safe with medication administration, patient can identify and manage symptoms, the patient was able to verbalize who to follow up with post discharge, agency staff notified the patient's physician of the discharge and the discharge would be sent to the physician within 5 days. d. Interview on 7/13/21 at 3:06 PM with agency Administrator/Registered Nurse who completed the discharge assessment, revealed he/she was unsure why the patient discharged. Staff A, Administrative Assistant entered the Administrator's office and reported the patient called and requested to be discharged to change services to another agency. The patient refused to tell the agency which agency he was changing services to. e. The discharge order, dated 6/23/21, ordered the agency to please discharge patient from the agency per patient request. f. A Discharge Summary included documentation of a signature of completion by the Administrator/RN, dated 6/23/21. The clinical record lacked any documentation of required education of risk and adverse outcomes from refusing services, communication with the patient's physician, measures taken to investigate the patient's refusal, and interventions the home health agency attempted in order to obtain patient participation with the plan of care prior to discharge of a patient who elects to be discharged . The above findings for Patient #2 were reviewed with agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to advise patients and/or the physician providing home health orders for the patient that discharge for cause is being considered for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #3 and #6) The agency reported a current census of 128 patients. The agency reported discharging 34 patients between 4/1/2021 and 7/12/2021. Failure to provide patient's with notification that discharge for cause is being considered denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include: According to the undated agency policy, titled Patient Bill of Rights and Responsibilities, agency staff will be responsible for knowing, observing and implementing the patient's rights and responsibilities on an ongoing basis. The Patient Bill of Rights and Responsibilities will be given to each patient at the time of the initial assessment and prior to admission. According to the undated Client (patient) Bill of Rights, the patient has the right to the following: Be informed of his or her rights; Exercise the rights at any time; Participate in, be informed about and consent to or refuse care in advance of and during treatment; and Receive proper written notice if the home health agency is reducing or terminating ongoing care. According to the undated agency policy, titled Patient Transfer/Agency Dissolution, the agency will initiate patient transfer and discharge when: The agency must dissolve and no longer in business; The agency is no longer capable of providing care needed. When one or more elements of the discharge criteria is met and another organization is appropriate to assume care. The need for discharge will be confirmed and the physician will be notified. The agency will speak with the patient by telephone or in person to at least 5 days before the date of discharge. The agency will document in the patient's chart that the patient's attending physician was notified of the discharge. According to the undated agency policy, titled Patient Discharge, agency staff will confirm the need for discharge and identify any remaining discharge planning needs. Staff will notify the physician of the need to discharge and obtain a discharge order. Staff will speak with the patient by telephone or in person 5 days before the date of discharge to ensure the patient's knowledge of the discharge. Each patient will be educated on aspects of post-discharge continuity of care arrangements. Medical record documentation for discharge includes the following: Progress toward goals/ discharge summary, Discharge Comprehensive Assessment, Discharge orders. Agency will have the patient or authorized representative complete and sign a generic notice. Patient or authorized representative should sign and date. Telephone or email contact may substitute for an in person visit to deliver notice and both require follow up with a written generic notice. A dated copy of the generic notice will be placed in the patient's medical file and is to include the name of person initiating contact, name of representative contacted, dated and time of contact and the telephone number. Agency will retain a copy and completed copies will be sent to the patient or authorized representative. 1. Patient #3 had a start of care date of 2/1/2021 and was discharged by the agency for cause on 4/20/2021. Clinical record review and associated patient and staff interviews included the following: a. The Plans of Care, dated 2/1/2021 to 4/1/2021 and 4/2/2021 to 5/31/2021, included physician orders for skilled nurse visits twice weekly to reconcile medications and instruct/educate/reinforce teaching related to the use of medications. b. Skilled nurse visit note, dated 4/19/2021 by Staff F, Licensed Practical Nurse (LPN), documented the patient misunderstood something the nurse said involving personal information shared with the patient's physician. The patient reportedly "blew up, making phone calls, stating (patient) was going to sue someone, yelling and screaming. This nurse excused herself and promptly left." c. The Communication Note, dated 4/20/2021, by Staff A, Administrative Assistant, reporting Patient #3's Amerigroup case manager contacted the agency to discuss the patient's behavior during the home visit the day before (4/19/2021). The Amerigroup case manager reported Patient #3 was disgruntled the previous day, had contacted the sheriff's office and they made a visit to the patient's home. The patient "seemed to have calmed down by the time officials arrived. The note documented the Amerigroup case manager "concurred the agency should discharge patient from services due to patient's behavior with staff in the home." d. During agency staff interview on 7/14/2021 at 12:30 PM, Staff F, LPN, reported she did routinely see Patient #3 twice weekly and gave androgen replacement injections every other week. On 4/19/2021 the LPN saw Patient #3 in the patient's home. The patient asked the nurse why the physician stopped providing a prescription for the androgen replacement medication. The LPN reported telling the patient some personal information was told to the physician that made the physician stop prescribing it. The patient got "angry and asked who told him that? I told him (Staff G, Registered Nurse (RN)) did and (the patient) started yelling- telling me (the patient) needed her last name because (the patient) was going to sue her. (The patient) got on the phone and was trying to make a call. (The patient) never threatened me at all. I just left because (the patient) was upset. I went to the home health office and told (Staff A, Administrative Assistant) about (the patient) getting upset and what happened. I told her I wasn't sure I wanted to see (the patient) if (the patient's) temper was so explosive. She said no one else wanted to see (the patient) either. So (the patient) was discharged after that and I never went back." e. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported receiving home health services from the agency in the past approximate 2 years. The patient report a nurse visited twice weekly since admission, administering an androgen replacement injection during one of the visits every other week until mid April. The physician stopped approving the prescription for the androgen replacement medication in mid April and the nurse was unable to give the injection. During the last visit made by the nurse, the patient reported the nurse told him/her she couldn't give me the injections anymore because Staff G, Registered Nurse (RN), shared some personal information with the physician, causing the physician to stop prescribing the medication. The patient reported the shared information was untrue and admitted to becoming very upset, yelling and threatening to sue. "The agency just stopped coming to see me." The patient denied requesting discharge or ever receiving any discharge paperwork from the agency. f. The update to the comprehensive assessment at the time of discharge, dated 4/20/2021, documented the patient requested to be discharged from agency services, despite the communication note indicating the patient would be discharged due to behaviors intimidating staff. g. The discharge summary, dated 4/20/2021, documented the agency discharged the patient at the request of the patient, despite the communication note indicating the patient would be discharged due to behaviors intimidating staff. h. The physician's order, dated 4/20/2021 and authored by the agency Administrator, stated "please discharge patient from Nurse At Home, Home Healthcare per patient request." even though the communication note indicated the patient would be discharged due to behaviors intimidating staff. i. The clinical record included a generic discharge form, dated and signed by the nurse on 2/1/2021 and dated by the patient on 2/1/2021. 2/1/2021 was the patient's admission date. The note read: "....... This letter is to notify you of discharge from our home care services, effective_______. The decision has been made to discharge you from our home care services for the following reason(s):" Multiple potential reasons are listed on the form with ( ) available to mark the reasons. The entire form was left blank. j. The clinical record lacked any other generic discharge forms. k. The clinical record lacked documentation of telephone, email or direct patient contact to notify the patient discharge for cause was being considered. 2. Patient #6 had a start of care date of 10/12/2018 and a discharge date of 5/24/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/30/2021 to 5/28/2021, included physician orders for skilled nursing services once weekly for 8 weeks. b. The patient was not home and was unable to be contacted, missing all skilled services during the first 5 weeks of the certification period. c. The skilled nurse visit notes, dated 5/14/2021 and 5/19/2021, documented the patient received care provided by Staff F, Licensed Practical Nurse (LPN). Both notes documented patient cooperation during the visit and lacked any documentation of concerns identified by the LPN. d. The physician's order, dated 5/24/2021 and signed by the physician on 6/4/2021, stated "please discharge patient from Nurse at Home, Home Healthcare for non-compliance". e. The clinical record included a generic discharge form, dated and signed by the nurse on 10/12/18 and dated and signed by the patient on 10/12/18. 10/12/18 was the patient's admission date. The note read: "....... This letter is to notify you of discharge from our home care services, effective_______. The decision has been made to discharge you from our home care services for the following reason(s):" Multiple potential reasons are listed on the form with ( ) available to mark the reasons. The entire form was left blank. f. The clinical record lacked any other generic discharge forms. g. The clinical record lacked documentation of telephone, email or direct patient contact to notify the patient discharge for cause was being considered. h. The Communication Note, dated 5/24/2021, documented a planned discharge at the request of Patient #6 despite the notification to the physician of the discharge for cause, citing noncompliance as the reason. i. The update to the comprehensive assessment at the time of discharge, dated 5/24/2021, documented the patient was being discharged at the request of the patient despite the notification to the physician of the discharge for cause, citing noncompliance as the reason. The above findings for Patients #3 and #6 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #3 and #6) The agency reported a current census of 128 patients. The agency reported discharging 34 patients between 4/1/2021 and 7/12/2021. Failure to attempt to initiate any efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include: According to the undated agency policy, titled Patient Bill of Rights and Responsibilities, agency staff will be responsible for knowing, observing and implementing the patient's rights and responsibilities on an ongoing basis. The Patient Bill of Rights and Responsibilities will be given to each patient at the time of the initial assessment and prior to admission. According to the undated Client (patient) Bill of Rights, the patient has the right to the following: Be informed of his or her rights; Exercise the rights at any time; Participate in, be informed about and consent to or refuse care in advance of and during treatment; and Receive proper written notice if the home health agency is reducing or terminating ongoing care. According to the undated agency policy, titled Patient Transfer/Agency Dissolution, the agency will initiate patient transfer and discharge when: The agency must dissolve and no longer in business; The agency is no longer capable of providing care needed; When one or more elements of the discharge criteria is met and another organization is appropriate to assume care. The need for discharge will be confirmed and the physician will be notified. The agency will speak with the patient by telephone or in person to at least 5 days before the date of discharge. The agency will document in the patient's chart that the patient's attending physician was notified of the discharge. According to the undated agency policy, titled Patient Discharge, agency staff will confirm the need for discharge and identify any remaining discharge planning needs. Staff will notify the physician of the need to discharge and obtain a discharge order. Staff will speak with the patient by telephone or in person 5 days before the date of discharge to ensure the patient's knowledge of the discharge. Each patient will be educated on aspects of post-discharge continuity of care arrangements. 1. Patient #3 had a start of care date of 2/1/2021 and was discharged by the agency for cause on 4/20/2021. Clinical record review and associated patient and staff interviews included the following: a. The Plans of Care, dated 2/1/2021 to 4/1/2021 and 4/2/2021 to 5/31/2021, included physician orders for skilled nurse visits twice weekly to reconcile medications and instruct/educate/reinforce teaching related to the use of medications. b. Skilled nurse visit note, dated 4/19/2021 by Staff F, Licensed Practical Nurse (LPN), documented the patient misunderstood something the nurse said involving personal information shared with the patient's physician. The patient reportedly "blew up, making phone calls, stating (patient) was going to sue someone, yelling and screaming. This nurse excused herself and promptly left." c. The Communication Note, dated 4/20/2021, by Staff A, Administrative Assistant, reporting Patient #3's Amerigroup case manager contacted the agency to discuss the patient's behavior during the home visit the day before (4/19/2021). The Amerigroup case manager reported Patient #3 was disgruntled the previous day, had contacted the sheriff's office and they made a visit to the patient's home. The patient "seemed to have calmed down by the time officials arrived. The note documented the Amerigroup case manager "concurred the agency should discharge patient from services due to patient's behavior with staff in the home." d. During agency staff interview on 7/14/2021 at 12:30 PM, Staff F, LPN, reported she did routinely see Patient #3 twice weekly and gave androgen replacement injections every other week. On 4/19/2021 the LPN saw Patient #3 in the patient's home. The patient asked the nurse why the physician stopped providing a prescription for the androgen replacement medication. The LPN reported telling the patient some personal information was told to the physician that made the physician stop prescribing it. The patient got "angry and asked who told him that? I told him (Staff G, Registered Nurse (RN)) did and (the patient) started yelling- telling me (the patient) needed her last name because (the patient) was going to sue her. (The patient) got on the phone and was trying to make a call. (The patient) never threatened me at all. I just left because (the patient) was upset. I went to the home health office and told (Staff A, Administrative Assistant) about (the patient) getting upset and what happened. I told her I wasn't sure I wanted to see (the patient) if (the patient's) temper was so explosive. She said no one else wanted to see (the patient) either. So (the patient) was discharged after that and I never went back." e. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported receiving home health services from the agency in the past approximate 2 years. The patient report a nurse visited twice weekly since admission, administering an androgen replacement injection during one of the visits every other week until mid April. The physician stopped approving the prescription for the androgen replacement medication in mid April and the nurse was unable to give the injection. During the last visit made by the nurse, the patient reported the nurse told him/her she couldn't give me the injections anymore because Staff G, Registered Nurse (RN), shared some personal information with the physician, causing the physician to stop prescribing the medication. The patient reported the shared information was untrue and admitted to becoming very upset, yelling and threatening to sue. "The agency just stopped coming to see me." The patient denied requesting discharge. f. The patient's clinical record lacked documentation of any efforts made to resolve the problem prior to discharge. The clinical record lacked documentation of any other instances of intimidating behavior prior to the 4/19/2021 incident. 2. Patient #6 had a start of care date of 10/12/2018 and a discharge date of 5/24/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/30/2021 to 5/28/2021, included physician orders for skilled nursing services once weekly for 8 weeks. b. The patient was not home and was unable to be contacted, missing all skilled services during the first 5 weeks of the certification period. c. The skilled nurse visit notes, dated 5/14/2021 and 5/19/2021, documented the patient received care provided by Staff F, Licensed Practical Nurse (LPN). Both notes documented patient cooperation during the visit and lacked any documentation of concerns identified by the LPN. d. The physician's order, dated 5/24/2021 and signed by the physician on 6/4/2021, stated "please discharge patient from Nurse at Home, Home Healthcare for non-compliance". e. The patient's clinical record lacked documentation of any efforts made to resolve the problem prior to discharge. The patient allowed the skilled nurse visit two weeks in a row immediately prior to the agency's involuntary discharge for non-compliance. The above findings for Patients #3 and #6 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to provide the patient with contact information for other agencies or providers who may be able to provide care prior to discharging the patient for cause for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #3 and #6) The agency reported a current census of 128 patients. The agency reported discharging 34 patients between 4/1/2021 and 7/12/2021. Failure to provide the patient with contact information of other agencies or providers who may be able to provide care after an involuntary discharge placed the patient at risk for inadequate care in the home setting to meet the needs of the patient, increasing the risk of illness or injury due lack of oversight. Findings include: According to the undated agency policy, titled Patient Bill of Rights and Responsibilities, agency staff will be responsible for knowing, observing and implementing the patient's rights and responsibilities on an ongoing basis. The Patient Bill of Rights and Responsibilities will be given to each patient at the time of the initial assessment and prior to admission. According to the undated Client (patient) Bill of Rights, the patient has the right to the following: Be informed of his or her rights; Exercise the rights at any time; Participate in, be informed about and consent to or refuse care in advance of and during treatment; and Receive proper written notice if the home health agency is reducing or terminating ongoing care. According to the undated agency policy, titled Patient Transfer/Agency Dissolution, the agency will initiate patient transfer and discharge when: The agency must dissolve and no longer in business; The agency is no longer capable of providing care needed; When one or more elements of the discharge criteria is met and another organization is appropriate to assume care. The need for discharge will be confirmed and the physician will be notified. The agency will speak with the patient by telephone or in person to at least 5 days before the date of discharge. The agency will document in the patient's chart that the patient's attending physician was notified of the discharge. According to the undated agency policy, titled Patient Discharge, agency staff will confirm the need for discharge and identify any remaining discharge planning needs. Staff will notify the physician of the need to discharge and obtain a discharge order. Staff will speak with the patient by telephone or in person 5 days before the date of discharge to ensure the patient's knowledge of the discharge. Each patient will be educated on aspects of post-discharge continuity of care arrangements. 1. Patient #3 had a start of care date of 2/1/2021 and was discharged by the agency for cause on 4/20/2021. Clinical record review and associated patient and staff interviews included the following: a. The Plans of Care, dated 2/1/2021 to 4/1/2021 and 4/2/2021 to 5/31/2021, included physician orders for skilled nurse visits twice weekly to reconcile medications and instruct/educate/reinforce teaching related to the use of medications. b. Skilled nurse visit note, dated 4/19/2021, by Staff F, Licensed Practical Nurse (LPN), documented the patient misunderstood something the nurse said involving personal information shared with the patient's physician. The patient reportedly "blew up, making phone calls, stating (patient) was going to sue someone, yelling and screaming. This nurse excused herself and promptly left." c. The Communication Note, dated 4/20/2021, by Staff A, Administrative Assistant, reporting Patient #3's Amerigroup case manager contacted the agency to discuss the patient's behavior during the home visit the day before (4/19/2021). The Amerigroup case manager reported Patient #3 was disgruntled the previous day, had contacted the sheriff's office and they made a visit to the patient's home. The patient "seemed to have calmed down by the time officials arrived. The note documented the Amerigroup case manager "concurred the agency should discharge patient from services due to patient's behavior with staff in the home." d. During agency staff interview on 7/14/2021 at 12:30 PM, Staff F, LPN, reported she did routinely see Patient #3 twice weekly and gave androgen replacement injections every other week. On 4/19/2021 the LPN saw Patient #3 in the patient's home. The patient asked the nurse why the physician stopped providing a prescription for the androgen replacement medication. The LPN reported telling the patient some personal information was told to the physician that made the physician stop prescribing it. The patient got "angry and asked who told him that? I told him (Staff G, Registered Nurse (RN)) did and (the patient) started yelling- telling me (the patient) needed her last name because (the patient) was going to sue her. (The patient) got on the phone and was trying to make a call. (The patient) never threatened me at all. I just left because (the patient) was upset. I went to the home health office and told (Staff A, Administrative Assistant) about (the patient) getting upset and what happened. I told her I wasn't sure I wanted to see (the patient) if (the patient's) temper was so explosive. She said no one else wanted to see (the patient) either. So (the patient) was discharged after that and I never went back." e. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported receiving home health services from the agency in the past approximate 2 years. The patient report a nurse visited twice weekly since admission, administering an androgen replacement injection during one of the visits every other week until mid April. The physician stopped approving the prescription for the androgen replacement medication in mid April and the nurse was unable to give the injection. During the last visit made by the nurse, the patient reported the nurse told him/her she couldn't give me the injections anymore because Staff G, Registered Nurse (RN), shared some personal information with the physician, causing the physician to stop prescribing the medication. The patient reported the shared information was untrue and admitted to becoming very upset, yelling and threatening to sue. "The agency just stopped coming to see me." The patient denied requesting discharge. The patient denied ever receiving contact information for any other local agencies or programs that may have been able to assist in the home upon discharge. f. The patient's clinical record lacked documentation indicating the agency provided a list of other local agencies who may be able to provide assistance in the home upon Nurse at Home discharge. 2. Patient #6 had a start of care date of 10/12/2018 and a discharge date of 5/24/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/30/2021 to 5/28/2021, included physician orders for skilled nursing services once weekly for 8 weeks. b. The patient was not home and was unable to be contacted, missing all skilled services during the first 5 weeks of the certification period. c. The skilled nurse visit notes, dated 5/14/2021 and 5/19/2021, documented the patient received care provided by Staff F, Licensed Practical Nurse (LPN). Both notes documented patient cooperation during the visit and lacked any documentation of concerns identified by the LPN. d. The physician's order, dated 5/24/2021 and signed by the physician on 6/4/2021, stated "please discharge patient from Nurse at Home, Home Healthcare for non-compliance". e. The patient's clinical record lacked documentation indicating the agency provided a list of other local agencies who may be able to provide assistance in the home upon Nurse at Home discharge. f. The patient could not be reached for interview. The above findings for Patients #3 and #6 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record review, patient/caregiver interview and agency staff interview, the agency failed to do the following: 1) ensure comprehensive assessments were updated timely by direct assessment in the patient's home (G520); 2) ensure comprehensive assessments included the patient's current health, psychosocial, functional, and cognitive status (G528); 3) ensure comprehensive assessments were updated and revised the last five days of every 60 day period beginning with start of care by assessing the patient directly in the patient's home (G546); 4) ensure comprehensive assessments were updated and revised 2 days after receiving knowledge of the patient's return home from an inpatient stay by assessing the patient directly in the patient's home (G548); and 3) ensure comprehensive assessments were updated at discharge by assessing the patient directly in the patient's home or by the last qualified clinician who assessed the patient directly in the case of an unexpected discharge where the nurse cannot visit the patient (G550); The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 128 patients.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, agency staff interview and patient/caregiver interview, the agency failed to ensure completion of the update to the comprehensive assessment with accompanying drug regimen review by performing an onsite assessment of the patient for 1 of 7 sampled patients (Patient #3). The agency provided services to 128 patients at the time of the survey. Failure to complete start of care comprehensive assessment by directly assessing the patient increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency's undated policy, titled Patient Assessment Guidelines, assessment information will be gathered and documented on the appropriate discipline's assessment form(s) by the primary provider. According to the agency's undated policy, titled Initial Patient Comprehensive Assessment, each patient will receive a patient specific, comprehensive assessment that incorporates Outcome and Assessment Information Set (OASIS) for Medicare and Medicaid patients, completed by a registered nurse (RN), physical therapist or speech therapist. The assessment will accurately reflect the patient's current health status and assist in uniformly and consistently measure patient outcomes. The comprehensive assessment will include but not limited to the following: Physical Assessment/Review of body systems; OASIS data set, including pertinent diagnoses, prognosis, physical findings and medical history; ADL/Functional Status; Medication history; Allergies; Psychosocial status; Assessment of the environment; Nutritional requirements; and Drug regimen review. Patient #3 had a start of care date of 2/1/2021 and was discharged from agency services on 4/20/2021. Clinical record review and associated staff and patient interviews revealed the following: a. The Communication Note, dated 2/1/2021, documented Staff G, Registered Nurse (RN), visited the patient to admit to services. The patient was "very confused, irritated and does not stay on task. (The patient) says does not like the original nurse (Staff G) and would like someone else to see (the patient). Staff F, Licensed Practical Nurse (LPN) and Staff B, RN Clinical Manager will be seeing (the patient) now." The note also documented Staff G, RN who saw the patient earlier in the day, had a personal conflict of interest with the patient and requested to no longer see the patient. The patient was immediately reassigned. b. The initial comprehensive assessment, dated 2/1/2021, was not electronically signed as complete. The agency's electronic medical record event log identified the Administrator/RN of the agency documented the assessment on 2/8/2021. The assessment lacked a physical assessment of the patient. c. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported being seen in his/her home by only one staff. The patient did not recognize the name of the Administrator and denied any contact with her. d. The clinical record lacked any documentation indicating the Administrator/RN of the agency had every directly assessed Patient #3 between 2/1/2021 and 4/20/2021. (All direct visits were made by Staff F, LPN) e. During agency staff interview on 7/14/2021 at 11:15 AM, the Administrator/RN of the agency reported Staff G, RN, directly assessed Patient #3 but, due to a personal conflict of interest, requested to have someone else be the primary RN. The Administrator/RN reported she used documentation collected by Staff G, RN, and telehealth (telephone only) assessment to complete the initial comprehensive assessment. f. The clinical record lacked any documentation completed by Staff G, RN, related to her direct assessment of Patient #3 at start of care. The Administrator/RN reported she had not visited Patient #3 in the home to perform the comprehensive assessment. She reported completing the comprehensive assessment by telephone interview only. The comprehensive assessment was never completed as the RN did not make an onsite visit to collect the physical assessment of the patient. (Please refer to G528 for associated information) The above findings for Patient #3 was reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient interview and agency staff interview, the agency failed to ensure accurate and thorough completion of all pertinent components of each comprehensive assessment for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7 and #8). The agency reported a current patient census of 128 patients. Failure to accurately and thoroughly complete comprehensive assessments to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency's undated policy, titled Patient Assessment Guidelines, assessment information will be gathered and documented on the appropriate discipline's assessment form(s) by the primary provider. According to the agency's undated policy, titled Initial Patient Comprehensive Assessment, each patient will receive a patient specific, comprehensive assessment that incorporates Outcome and Assessment Information Set (OASIS) for Medicare and Medicaid patients, completed by a registered nurse (RN), physical therapist or speech therapist. The assessment will accurately reflect the patient's current health status and assist in uniformly and consistently measure patient outcomes. The comprehensive assessment will include but not limited to the following: Physical Assessment/Review of body systems; OASIS data set, including pertinent diagnoses, prognosis, physical findings and medical history; ADL/Functional Status; Medication history; Allergies; Psychosocial status; Assessment of the environment; Nutritional requirements; and Drug regimen review. 1. Patient #1 had a start of care date of 6/15/21. Clinical record review revealed: a. The Plan of Care, dated 6/15/21 to 8/13/21, identified Medicare as the patient's payor source. b. The consent for Care/Services, Authorization for Release of Information, and Liability for Payment Form, completed at admission on 6/15/21, documented the agency will bill Medicare for agency services and the patient did not have a HMO (Health Maintenance Organization). c. The initial comprehensive assessment at the time of start of care, dated 6/15/2021, documented current payment sources for home care included Medicare traditional fee for service and Medicare HMO/managed care/Advantage Plan. The comprehensive assessment at start of care incorrectly identified current payment sources for home care. 2. Patient #2 had a start of care date of 12/9/2020 and was discharged from the agency on 6/23/21. Clinical record review revealed: a. The Plans of Care, dated 12/9/2020 to 2/6/21, 2/7/21 to 4/7/21, 4.8/21 to 6/6/21 and 6/7/21 to 8/5/21, identified Medicare as the patient's payor source. b. The consent for Care/Services, Authorization for Release of Information, and Liability for Payment Form completed at admission dated 12/9/2020, documented the agency will bill Medicare and Medicaid for agency services and the patient had a HMO (Health Maintenance Organization). c. The initial comprehensive assessment at the time of start of care, dated 12/9/2020, documented current payment sources for home care included Medicare traditional fee for service, Medicare HMO/managed care/Advantage Plan, Medicaid traditional fee for service, and Medicaid HMO/Managed Care. The comprehensive assessment at start of care incorrectly identified current payment sources for home care. d. The updates to the comprehensive assessment for recertification, dated 2/3/21, 4/7/21, 6/2/21, documented current payment sources for home care included Medicare traditional fee for service, Medicare HMO/managed care/Advantage Plan, Medicaid traditional fee for service, and Medicaid HMO/Managed Care. e. Interview with agency Administrator on 7/14/21 at 10:35 AM revealed the Administrator completed the 4/7/21 assessment as a Registered Nurse (RN) over the telephone as a telemed visit and vital signs and physical assessment were unable to be collected for that reason. Comprehensive assessments must be completed in person in order to fully complete a head to toe assessment of the patient. The comprehensive assessments at recertification incorrectly identified current payment sources for home care and the recertification assessment completed in person on 4/7/21 per OASIS requirements. f. The update to the comprehensive assessment for discharge, dated 6/23/21, documented current payment sources for home care included Medicare traditional fee for service, Medicare HMO/managed care/Advantage Plan, Medicaid traditional fee for service, and Medicaid HMO/Managed Care. g. Interview with agency Administrator on 7/14/21 at 10:35 AM revealed the Administrator completed the assessment as a Registered Nurse (RN) over the telephone as a telemed visit and vital signs and physical assessment were unable to be collected for that reason. Comprehensive assessments must be completed in person in order to fully complete a head to toe assessment of the patient or for discharge by the last clinician who visited the patient in the home. The comprehensive assessments at discharge incorrectly identified current payment sources for home care and the discharge assessment was not completed in person or by the last clinician who visited the patient in the home per OASIS requirements. 3. Patient #7 had a start of care date of 11/23/2020 and a discharge date of 4/29/21. Clinical record review revealed: a. The Plans of Care, dated 11/23/2020 to 1/21/21, 1/22/21 to 3/22/21, and 3/23 to 5/21/21, identified Medicare as the patient's payor source. b. The consent for Care/Services, Authorization for Release of Information, and Liability for Payment Form, completed at admission on 11/23/2020, documented the agency will bill Medicare for agency services and the patient did have a HMO (Health Maintenance Organization). c. The update to the comprehensive assessment for recertification, dated 1/18/21, documented the patient had received a new leg brace for the left leg due to prior history of automobile accident and the brace rubbed into the patient's left posterior thigh causing a scabbed area. The nurse documented the patient did not have an unhealed pressure ulcer/injury at stage 2 or higher or designated as unstageable. The comprehensive assessment at recertification lacked documentation of measurements, including length and width of the scabbed area noted to the left leg. c. The updates to the comprehensive assessment for recertification, dated 1/18/21 and 3/22/21, documented current payment sources for home care included Medicare traditional fee for service and Medicare HMO/managed care/Advantage Plan. The comprehensive assessments at recertification incorrectly identified current payment sources for home care. 4. Patient #8 had a start of care date of 6/9/21. Clinical record review revealed: a. The Plan of Care, dated 6/9/21 to 8/7/21, identified Medicare as the patient's payor source. b. The consent for Care/Services, Authorization for Release of Information, and Liability for Payment Form, completed at admission on 6/9/21, documented the agency will bill Medicare for agency services and the patient did not have a HMO (Health Maintenance Organization). c. The initial comprehensive assessment at the time of start of care, dated 6/9/2021, documented current payment sources for home care included Medicare traditional fee for service and Medicare HMO/managed care/Advantage Plan. The comprehensive assessment at start of care incorrectly identified current payment sources for home care. 5. Patient #5 had a start of care date of 2/1/2021 and was discharged from home health services on 4/20/2021. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of start of care, dated 2/2/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare, a Medicare Advantage Plan, traditional fee for service Medicaid and a Medicaid Managed Care Organization for the patient's services. The agency was billing only the Medicare Advantage Plan for the patient's services. The assessment lacked documentation of all vital signs, including temperature, pulse, respirations, blood pressure. The assessment lacked a height and weight of the patient. The assessment included documentation of a reconciliation of the medications taken by the patient and a drug regimen review; however, the patient's clinical record and Plan of Care did not include any of the patient's medications until the second certification period. The initial assessment was completed by the RN over the telephone. No onsite visit was made to the patient's home, making physical assessment and observation of each medication taken by the patient impossible. b. The update to the comprehensive assessment at the time of recertification, dated 4/2/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare, a Medicare Advantage Plan, traditional fee for service Medicaid and a Medicaid Managed Care Organization for the patient's services. The agency was billing only the Medicare Advantage Plan for the patient's services. The assessment lacked documentation of all vital signs, including temperature, pulse, respirations, blood pressure. The assessment included a height and weight of the patient; however, both would have been stated by the patient. The drug regimen review was completed without an actual review of the patient's medications in the home. The up date to the assessment was completed by the RN over the telephone. No onsite visit was made to the patient's home, making physical assessment and observation of each medication taken by the patient impossible. c. The update to the comprehensive assessment at the time of discharge, dated 4/20/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare, a Medicare Advantage Plan, traditional fee for service Medicaid and a Medicaid Managed Care Organization for the patient's services. The agency was billing only the Medicare Advantage Plan for the patient's services. The assessment lacked documentation of all vital signs, including temperature, pulse, respirations, blood pressure. The assessment lacked a height and weight of the patient. The drug regimen review was completed without an actual review of the patient's medications in the home. The update to the comprehensive assessment was completed by the RN over the telephone. No onsite visit was made to the patient's home, making physical assessment and observation of each medication taken by the patient impossible. (Please see G520, G546 and G550 for associated information) 6. Patient #6 had a start of care date of 8/31/2020. Clinical record review revealed the following: The update to the comprehensive assessments at the time of recertification, dated 4/27/2021 and 6/23/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare, a Medicare Advantage Plan, traditional fee for service Medicaid and a Medicaid Managed Care Organization for the patient's services. The agency was billing only the Medicare traditional fee for service for the patient's services. 7. Patient #5 had a start of care date of 12/29/2020 and was discharged from home health services on 4/22/2021. Clinical record review revealed the following: The initial comprehensive assessment at the time of start of care, dated 12/29/2020, lacked the following physical assessment findings or included inaccurate findings: a. M0150- current pay source documented the agency planned to bill traditional fee for service Medicare and Medicare Advantage Plan for the patient's services. The agency was billing only the Medicare Advantage Plan for patient's services. The assessment lacked blood sugar readings for fasting and random blood sugars to use for a baseline. b. The update to the comprehensive assessment at the time of resumption of care, dated 2/9/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare and Medicare Advantage Plan for the patient's services. The agency was billing only the Medicare Advantage Plan for patient's services. The assessment lacked blood sugar readings for fasting and random blood sugars to use for a new baseline stating "patient is non-compliant with diabetes". Hospital discharge paperwork, dated 2/9/2021, documented labs taken upon admission to the hospital on 2/2/2021 revealed patient's blood glucose levels were greater than 800. c. The update to the comprehensive assessment at the time of recertification, dated 2/23/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare and Medicare Advantage Plan for the patient's services. The agency was billing only the Medicare Advantage Plan for patient's services. The assessment lacked blood sugar readings for fasting and random blood sugars stating "patient is non-compliant with diabetes.". d. The update to the comprehensive assessment at the time of resumption of care, dated 3/4/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare and Medicare Advantage Plan for the patient's services. The agency was billing only the Medicare Advantage Plan for patient's services. The assessment lacked blood sugar readings for fasting and random blood sugars to use for a new baseline stating "patient is non-compliant with diabetes". e. The update to the comprehensive assessment at the time of resumption of care, dated 3/18/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare and Medicare Advantage Plan for the patient's services. The agency was billing only the Medicare Advantage Plan for patient's services. The assessment lacked blood sugar readings for fasting and random blood sugars to use for a new baseline stating "patient is non-compliant with diabetes". Hospital discharge paperwork, dated 3/17/2021, documented labs taken upon admission to the hospital on 3/14/2021 revealed patient's blood glucose levels were greater than 600. f. The update to the comprehensive assessment at the time of resumption of care, dated 3/25/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare and Medicare Advantage Plan for the patient's services. The agency was billing only the Medicare Advantage Plan for patient's services. The assessment lacked blood sugar readings for fasting and random blood sugars to use for a new baseline. Hospital discharge paperwork, dated 3/23/2021, revealed patient's blood glucose level was 685 upon admission to the hospital. g. The update to the comprehensive assessment at the time of resumption of care, dated 4/19/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare and a Medicare Advantage Plan for the patient's services. The agency was billing only the Medicare Advantage Plan for the patient's services. The assessment lacked documentation of all vital signs, including temperature, pulse, respirations, blood pressure. The assessment lacked a height and weight of the patient. The assessment lacked a blood sugar reading for fasting and random to allow for a baseline. Hospital discharge paperwork, dated 4/15/2021, documented the patient's blood sugar level was 686 upon admission to the hospital. The drug regimen review was completed without an actual review of the patient's medications in the home. The update to the comprehensive assessment was completed by the RN over the telephone. No onsite visit was made to the patient's home, making physical assessment and observation of each medication taken by the patient impossible. (Please see G548 for associated information) 8. Patient #6 had a start of care date of 10/12/2018 and was discharged from home health services on 5/24/2021. Clinical record review revealed the following: a. The updates to the comprehensive assessment at the time of recertification, dated 11/25/2020, 1/25/2021 and 3/29/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare, a Medicare Advantage Plan, traditional fee for service Medicaid and a Medicaid Managed Care Organization for the patient's services. The agency was billing only the Medicaid Managed Care Organization for patient's services. b. The update to the comprehensive assessment at the time of discharge, dated 5/24/2021, lacked the following physical assessment findings or included inaccurate findings: M0150- current pay source documented the agency planned to bill traditional fee for service Medicare, a Medicare Advantage Plan, traditional fee for service Medicaid and a Medicaid Managed Care Organization for the patient's services. The agency was billing only the Medicaid Advantage Plan of the patient's services. The assessment lacked documentation of all vital signs, including temperature, pulse, respirations, blood pressure. The assessment lacked a height and weight of the patient. The drug regimen review was completed without an actual review of the patient's medications in the home. The update to the comprehensive assessment was completed by the RN over the telephone. No onsite visit was made to the patient's home, making physical assessment and observation of each medication taken by the patient impossible. (Please see G550 for associated information) The above findings for Patients #1, #2, #3, #4, #5, #6, #7, and #8 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review, patient interview and agency staff interview, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 5 of 6 sampled patients requiring a recertification assessment (Patients #2, #3, #4, #6 and #7). The agency reported a census of 128 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency's undated policy, titled Patient Assessment Guidelines, assessment information will be gathered and documented on the appropriate discipline's assessment form(s) by the primary provider. According to the agency's undated policy, titled Initial Patient Comprehensive Assessment, each patient will receive a patient specific, comprehensive assessment that incorporates Outcome and Assessment Information Set (OASIS) for Medicare and Medicaid patients, completed by a registered nurse (RN), physical therapist or speech therapist. The assessment will accurately reflect the patient's current health status and assist in uniformly and consistently measure patient outcomes. The comprehensive assessment will include but not limited to the following: Physical Assessment/Review of body systems; OASIS data set, including pertinent diagnoses, prognosis, physical findings and medical history; ADL/Functional Status; Medication history; Allergies; Psychosocial status; Assessment of the environment;Nutritional requirements; and Drug regimen review. According to the agency's undated policy, titled Patient Reassessment/Recertification/Significant Change in Condition/Post Hospital Assessment, each patient will be reassessed during the last five days of the episode (certification period). 1. Patient #2 had a start of care date of 12/9/2020 and a discharge date of 6/23/21. Clinical record revealed the following: a. The Plans of Care, dated 2/7/21 to 4/7/21 and 4/8/21 to 6/6/21, included physician orders for skilled nursing and home health aide services. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 4/7/21 (day 60 of the certification period) but was not completed until 4/15/21, 8 days into the new certification period. The certification period ended on 4/7/21. The assessment was not completed by day 60 as required by regulation and agency policy. c. Interview with agency Administrator on 7/14/21 at 10:35 AM revealed the Administrator completed the assessment as a Registered Nurse (RN) over the telephone as a telemed visit and vital signs and physical assessment were unable to be collected for that reason. Comprehensive assessments must be completed in person in order to fully complete a head to toe assessment of the patient. The agency failed to complete/update the comprehensive assessment in the last 5 days of the 60 day episode. 2. Patient #7 had a start of care date of 11/23/2020 and a discharge date of 4/29/21. Clinical record revealed the following: a. The Plans of Care, dated 1/22/21 to 3/22/21 and 3/23/21 to 5/21/21, included physician orders for skilled nursing and home health aide services. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 3/22/21 (day 60 of the certification period) but was not completed until 3/23/21, 1 day into the new certification period. The certification period ended on 3/22/21. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessments in the last 5 days of each 60 day episode. 3. Patient #3 had a start of care date of 2/1/2021 and a discharge date of 4/20/2021. Clinical record review revealed the following: a. The Plans of Care, dated 2/1/2021 to 4/1/2021 and 4/2/2021 to 5/31/2021, included physician orders for skilled nursing services. b. The Communication Note, dated 2/1/2021, documented Staff G, RN, visited the patient to admit to services. Staff G, RN, had a personal conflict of interest with the patient and request to no longer see the patient. The patient was immediately reassigned to Staff F, Licensed Practical Nurse (LPN) and Staff B, RN Clinical Manager. c. The update to the comprehensive assessment at the time of recertification, dated 4/1/2021 and signed by Staff B, Registered Nurse (RN) Clinical Manager, lacked any physical assessment findings. d. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported being seen in his/her home by only one staff. The patient did not recognize the name of Staff B, RN Clinical Manager, and denied any contact with her. e. During agency staff interview on 7/14/2021 at 11:50 AM, Staff B, RN Clinical Manager reported she had not visited Patient #3 in the home to perform the comprehensive assessment. She reported completing the comprehensive assessment by telehealth (by telephone only) interview. Staff B, RN Clinical Manager, denied being the primary RN for Patient #3 and indicated she had never seen the patient directly. f. The clinical record lacked documentation indicating Staff B, RN Clinical Manager had ever examined Patient #3 directly between 2/1/2021 and 4/20/2021. (All direct visits were made by Staff F, LPN) The comprehensive assessment was never completed as the RN did not make an onsite visit to collect the physical assessment of the patient. (Please refer to G528 and G550 for associated information) 4. Patient #4 had a start of care date of 8/31/2020. Clinical record review revealed the following: a. The Plans of Care, dated 2/27/2021 to 4/27/2021 and 4/28/2021 to 6/26/2021, included physician orders for skilled nursing services and home health aide services. b. The update to the comprehensive assessment at the time of recertification, dated as begun on 4/27/2021, (day 60 of the certification period) but was not completed until 5/9/2021, 12 days into the new certification period. The certification period ended on 4/27/2021. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. 5. Patient #6 had a start of care date of 10/12/2018 and was discharged from home health services on 5/24/2021. Clinical record review revealed the following: The Plans of Care, dated 10/1/20201 to 11/29/2020, 11/30/2020 to 1/28/2021 and 1/29/2021 to 3/29/2021, included physician orders for skilled nursing services and home health aide services. a. The update to the comprehensive assessment at the time of recertification, dated 11/25/2020, was never electronically signed as complete. The agency's electronic medical record system event log documented Staff H, RN, documented the assessment with the last documentation occurring on 11/30/2021, the first day of the new certification period. b. The update to the comprehensive assessment at the time of recertification, dated 1/25/2021, was never electronically signed as complete. The agency's electronic medical record system event log documented Staff H, RN, documented the assessment with the last documentation occurring on 1/28/2021, however, never electronically signed the document. The Plan of Care, dated 3/30/2021 to 5/28/2021, included physician orders for skilled nursing services. c. The update to the comprehensive assessment at the time of recertification, dated 3/29/2021, (day 60 of the certification period) but was not completed until 4/2/2021, 4 days into the new certification period. The certification period ended on 3/29/2021. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. The above findings for Patients #2, #3, #4, #6 and #7 with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient interview and agency staff interview, the agency failed to ensure completion of the update to the comprehensive assessment with accompanying drug regimen review within 48 hours of the agency's knowledge of return home from an inpatient facility by performing an onsite assessment of the patient for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #5). The agency provided services to 128 patients at the time of the survey. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency's undated policy, titled Patient Assessment Guidelines, assessment information will be gathered and documented on the appropriate discipline's assessment form(s) by the primary provider. According to the agency's undated policy, titled Initial Patient Comprehensive Assessment, each patient will receive a patient specific, comprehensive assessment that incorporates Outcome and Assessment Information Set (OASIS) for Medicare and Medicaid patients, completed by a registered nurse (RN), physical therapist or speech therapist. The assessment will accurately reflect the patient's current health status and assist in uniformly and consistently measure patient outcomes. The comprehensive assessment will include but not limited to the following: Physical Assessment/Review of body systems; OASIS data set, including pertinent diagnoses, prognosis, physical findings and medical history; ADL/Functional Status;Medication history; Allergies; Psychosocial status; Assessment of the environment; Nutritional requirements; and Drug regimen review. According to the agency's undated policy, titled Patient Reassessment/Recertification/Significant Change in Condition/Post Hospital Assessment, the RN or therapist will compete the resumption of care comprehensive assessment within 48 hours of the patient's discharge from the hospital or other inpatient facility. Patient #5 had a start of care date of 12/29/2020 and was discharged from home health services on 4/22/2021. Clinical record review revealed the following: a. The Transfer assessment, dated 4/14/2021, documented Patient #5 was hospitalized on 4/14/2021. b. The update to the comprehensive assessment at the time of resumption of care, dated 4/19/2021 and signed by the Administrator/Owner, documented the patient was discharged from the hospital on 4/17/2021. The update to the assessment lacked documentation of any physical assessment of the patient. c. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported being seen in his/her home by only one staff. The patient did not recognize the name of the Administrator and denied any contact with her. d. During agency staff interview on 7/14/2021 at 11:05 AM, the Administrator/RN reported she had not visited Patient #3 in the home to perform the comprehensive assessment. She reported completing the comprehensive assessment by telehealth (by telephone only) interview and indicated she had never assessed the patient directly. e. The clinical record lacked documentation indicating the Administrator/RN had ever examined Patient #3 directly between 2/1/2021 and 4/20/2021. (All direct visits were made by Staff F, LPN) The comprehensive assessment was never completed as the RN did not make an onsite visit to collect the physical assessment of the patient. (Please refer to G528 for associated information) The above findings for Patient #5 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and agency staff interview, the agency failed to ensure completion of all required components of the discharge comprehensive assessments within 2 calendar days of identification of the need to discharge a patient for 3 of 3 sampled patients requiring a discharge comprehensive assessment (Patients #2, #3 and #6). The agency reported a census of 128 patients at the time of the survey and discharged 34 patients in the time period 4/1/21 to 7/12/21. Failure to accurately and thoroughly complete discharge comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency's undated policy, titled Patient Assessment Guidelines, assessment information will be gathered and documented on the appropriate discipline's assessment form(s) by the primary provider. According to the agency's undated policy, titled Initial Patient Comprehensive Assessment, each patient will receive a patient specific, comprehensive assessment that incorporates Outcome and Assessment Information Set (OASIS) for Medicare and Medicaid patients, completed by a registered nurse (RN), physical therapist or speech therapist. The assessment will accurately reflect the patient's current health status and assist in uniformly and consistently measure patient outcomes. The comprehensive assessment will include but not limited to the following: Physical Assessment/Review of body systems; OASIS data set, including pertinent diagnoses, prognosis, physical findings and medical history; ADL/Functional Status; Medication history; Allergies; Psychosocial status; Assessment of the environment; Nutritional requirements; and Drug regimen review. According to the agency's undated policy, titled Patient Discharge, the discharge assessment is completed within 48 hours of knowledge of the discharge. The discharge assessment is completed by the last discipline in the home (RN, PT, OT). In the event the discharge is not planned, the OASIS data is based on the last assessment collected by the RN, PT or OT. 1. Patient #2 had a start of care date of 12/9/2020 and a discharge date of 6/23/21. Clinical record revealed the following: a. The Plans of Care, dated 2/7/21 to 4/7/21 and 4/8/21 to 6/6/21, included physician orders for skilled nursing and home health aide services. b. The update to the comprehensive assessment for recertification, dated as initiated and completed on 6/2/21, was completed by Staff B, Registered Nurse (RN) Case Manager. c. All routine visits from 6/3/21 to 6/22/21 were completed by a licensed practical nurse. d. The update to the comprehensive assessment for discharge, dated as initiated and documented as completed on 6/23/21, was completed by agency Administrator/Registered Nurse (RN). e. Interview with agency Administrator on 7/14/21 at 10:35 AM, the Administrator reported he/she completed the assessment as a Registered Nurse (RN) over the telephone as a telemed visit and vital signs and physical assessment were unable to be collected for that reason. Comprehensive assessments must be completed in person in order to fully complete a head to toe assessment of the patient or for discharge by the last clinician who visited the patient in the home. The agency failed to complete/update the comprehensive assessment at discharge per regulations. 2. Patient #3 had a start of care date of 2/1/2021 and was discharged from agency services on 4/20/2021. Clinical record review and associated staff and patient interviews revealed the following: a. The update to the comprehensive assessment at the time of discharge, dated 4/20/2021, was completed by the Administrator/Owner. b. During patient interview on 7/14/2021 at 8:45 AM, Patient #3 reported being seen in his/her home by only one staff. The patient did not recognize the name of the Administrator and denied any contact with her. c. The clinical record lacked any documentation indicating the Administrator/RN of the agency had every directly assessed Patient #3 between 2/1/2021 and 4/20/2021. (All direct visits were made by Staff F, LPN) d. During agency staff interview on 7/14/2021 at 11:15 AM, the Administrator/Owner of the agency reported she had not visited the patient to complete the discharge assessment as the patient "fired us". The Administrator/RN admitted she had never directly assessed Patient #3 between 2/1/2021 and 4/20/2021. She reported copying everything from the update to the assessment at the time of recertification, which was completed by Staff B, RN Clinical Manager. "so everything is the same as that." e. The comprehensive assessment was never completed as the RN did not make an onsite visit to collect the physical assessment of the patient. (Please refer to G520, G528 and G546 for associated information) 3. Patient #6 had a start of care date of 10/12/2018 and was discharged from home health services on 5/24/2021. Clinical record review and associated staff and patient interviews revealed the following: a. The update to the comprehensive assessment at the time of discharge, dated 5/24/2021, was completed by the Administrator/RN on 6/1/2021, 6 days late. The assessment lacked any documentation of a physical assessment. b. The clinical record lacked any documentation indicating the Administrator/RN of the agency had every directly assessed Patient #6 between 11/30/2020 to 5/24/2021. (The time period reviewed by the surveyor) c. During agency staff interview on 7/14/2021 at 1:30 PM, the Administrator/RN the agency reported she had not visited the patient to complete the discharge assessment. The Administrator reported completing the assessment by telehealth (telephone visit only). d. The comprehensive assessment was completed late and the RN did not make an onsite visit to collect the physical assessment of the patient. (Please refer to G528 for associated information) The above findings for Patients #2, #3, and #6 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record review, patient interview and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 4 of 8 sampled patients (Patients #2, #4, #6 and #8). The agency reported a census of 128 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the agency's undated policy, titled Implementing Care and Treatment, when the provision of care/treatment cannot be implemented as established on the Plan of Care, the patient's physician will be notified. The appropriate documentation will be completed and submitted by discipline or Patient Care Manager. During agency staff interview on 7/14/2021 at 10:35 AM, the Administrator revealed home health aides do not know how to document physician notification on the missed visit form. Staff A, Administrative Assistant, came to the Administrator's office and revealed home care aides come to the office and fax the missed visit sheet to the physician. If the home health aides are unable to fax the sheet, the Administrative Assistant will fax the notification to the physician. The Administrative Assistant keeps a log of when the missed visit notifications are sent to the physician and provided the log to the surveyors. Staff A, Administrative Assistant also reported the physical therapists and occupational therapists do not do any of the faxing so the Administrative Assistant does this for them and sometimes the nurses if they can't complete the task. 1. Patient #2 had a start of care date of 12/9/2020 and a discharge date of 6/23/21. Clinical record review revealed: a. The Plan of Care, dated 2/7/21 to 4/7/21, included physician orders for home health aide visits one time per week for one week and three times per week for seven weeks. b. A missed visit note, dated 3/25/21, documented the home health aide visit was unable to be completed due to the patient not answering the phone after several attempts. The missed visit note stated the physician was not notified. c. The surveyor reviewed the missed visit fax log to the physician on 7/14/21. The log did not include the missed visit for 3/25/21. d. The Plan of Care, dated 4/8/21 to 6/6/21 and 6/7/21 to 8/5/21, included physician orders for skilled nursing visits two times per week. e. The week of 4/25/21, the clinical record included only one skilled nursing visit on 4/28/21. No documentation was found as to why the second nursing visit did not occur. f. The week of 6/13/21, the clinical record included only one skilled nursing visit on 6/16/21. No documentation was found as to why the second nursing visit did not occur. The clinical record lacked documentation of any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in skilled nursing and home health aide visit frequency. 2. Patient #8 had a start of care date of 6/9/2021. Clinical record review revealed: a. The Plan of Care, dated 6/9/21 to 8/7/21, included physician orders for skilled nursing visits weekly for nine weeks and occupational therapy visits two times per two weeks and then one time per week for two weeks. b. A missed visit note, dated 6/22/21, documented the skilled nurse was unable to visit the patient as the door was locked and no one answered the door. The missed visit note stated the physician was not notified. c. The surveyor reviewed the missed visit fax log to the physician on 7/14/21. The log did not include the missed visit for 6/22/21. d. A missed visit note, dated 6/23/21, documented the patient did not answer the door and the therapist called the patient who stated, he/she was with a friend and asked to reschedule due to going to be out of town. e. The surveyor reviewed the missed visit fax log to the physician on 7/14/21. The log did not include the missed visit for 6/23/21. The clinical record lacked documentation of any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in skilled nursing and occupational therapist visit frequency. 3. Patient #4 had a start of care date of 8/31/2020. Clinical record review revealed the following: a. The Plans of Care, dated 4/28/2021 to 6/26/2021 and 6/27/2021 to 8/25/2021, included physician orders for skilled nurse visits once weekly and home health aide visits for personal care assistance twice weekly. b. The home health aide assignment, dated 4/28/2021, directed the home health aide to assist the patient with bathing in a tub or shower every visit; assist with dressing every visit; apply lotion to the patient's back every visit; shampoo and comb the patient's hair every visit; assist with oral care every visit, assist with toileting every visit; assist with incontinence care every visit, assist the patient with transferring from one surface to another every visit; clean/file the patient's nails weekly and shave the patient weekly. c. The home health aide visit notes, dated 5/14, 24, 28/2021 and 6/7, 11, 28/2021, documented Patient #4 refused all personal care services during the home visits. Agency staff completed homemaking duties during the visits. d. During patient interview on 7/14/2021 at 9:00 AM, Patient #4 reported he/she required a home health aide present when bathing for safety reasons when getting out of a claw foot bathtub. The patient indicated there are times when the aide does not have to help and others when the aide does depending on the strength of the patient's legs that day. The patient reported being able wash when in the tub, dress, shampoo, comb hair, brush teeth, toilet, transfer, ambulate and change incontinence pads independently. e. The clinical record lacked any documentation of physician notification to report the inability to perform any of the ordered/assigned personal care tasks during the above stated visits. f. The missed visit/fax log kept by the agency to corroborate physician notification of missed visits lacked any documentation of notification being sent to the physician reporting the above stated missed visits. 4. Patient #6 had a start of care date of 10/12/2018 and was discharged from home health services on 5/24/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/30/2021 to 5/28/2021, included physician orders for skilled nurse visits once weekly. b. The clinical record lacked documentation of any skilled nursing visits during the weeks of 4/5/2021 to 4/10/2021; 4/11/2021 to 4/17/2021; 4/18/2021 to 4/24/2021; 4/25/2021 to 5/1/2021 and 5/2/2021 to 5/8/2021. The notes documented the nurse went to the patient's home on the day scheduled, finding the patient was not home and attempts to reach the patient were unsuccessful. c. The clinical record included missed visit notes for all of the above stated dates and documented the physician was notified; however, lacked identification of how the physician was notified. d. The clinical record lacked documentation of any telephone or written communication with the physician. e. The missed visit/fax log kept by the agency to corroborate physician notification of missed visits lacked any documentation of notification being sent to the physician reporting the above stated missed visit. The above stated findings for Patient #2, #4, #6 and #8 were reviewed with the Administrator and Staff A, Administrative Assistant. The agency provided no additional information prior to the end of the survey.

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 clinical record review, agency policy review, and agency staff interview, the agency failed to notify the physician of changes in patient condition or needs that suggest an alteration to the Plan of Care for 1 of 8 sampled patients (Patient #2). The agency reported a current census of 128 patients. Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: According to the agency's undated policy, titled Orders for Care, the agency will obtain orders and provide care in accordance with physician's orders which are established prior to initiating patient care and reviewed/revised by the physician every 60 days and as needed. All orders are kept current and updated as appropriate with changes in patient condition. If, at any time, part of the care required is not provided, then the physician will be notified. According to the agency's undated policy, titled Implementing Care and Treatment, when the provision of care cannot be implemented as established on the Plan of Care, the patient's physician will be notified. Patient #2 had a start of care date of 12/9/2020 and a discharge date of 6/23/21. Clinical record review revealed: a. The Plan of Care, dated 4/8/2021 to 6/6/2021 and 6/7/21 to 8/5/21, documented the diagnoses of hypoglycemia. The Plan of Care ordered skilled nursing services 2 times per week and home health aide services 5 times per week. b. The update to the comprehensive assessment for recertification, dated 4/7/21, was completed by telehealth (over the phone) by the Administrator. The documentation stated the patient was diagnosed with diabetes and no blood sugar ranges were specified and the patient was on insulin. c. Skilled nursing visit note, dated 4/14, 4/13, 4/19 and 4/22/21, and completed by the licensed practical nurse (LPN), documented the patient had diabetes and was on insulin, no blood sugar ranges given and the patient was noncompliant with checking blood sugar reading. The visit note included interventions for the skilled nurse to perform fasting blood sugar every visit using patient's glucometer to assess signs and symptoms of hypo/hyperglycemia or accuracy of reported blood sugars and the skilled nurse is to report fasting blood sugars greater than 250 milligrams (mg) per deciliter (dl) or less than 60 mg/dl and random blood sugars greater than 300 mg/dl or less than 70 mg/dl to the physician. The narrative note documented the patient has not checked blood sugar today and has not been checking blood sugars or eating a diabetic diet. d. Skilled nursing visit note, dated 4/28/21 and completed by the LPN, documented the patient had diabetes and fasting blood sugar ranges of 90 to 200 mg/dl and random blood sugar ranges of 200 to 500 mg/dl and the patient's blood glucose last night was 411 mg/dl. e. Skilled nursing visit note, dated 4/28/21 and completed by the LPN, documented the patient had diabetes and fasting blood sugar ranges of 100 to 101 mg/dl and random blood sugar ranges of 150 to 500 mg/dl and the patient only checked blood sugars at night with sliding scale insulin. f. Skilled nursing visit note, dated 5/5/21 and completed by the LPN, documented the patient had diabetes and blood sugars were performed by the patient and diabetic management of diet, exercise, and insulin use was administered by the patient. g. Skilled nursing visit note, dated 5/10/21 and completed by the LPN, documented the patient had diabetes and fasting blood sugar ranges of 100 to 400 mg/dl and random blood sugar ranges of 250 to 450 mg/dl. h. Skilled nursing visit note, dated 5/12/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 250 to 500 mg/dl and the patient does not check blood glucose reading in the morning. i. Skilled nursing visit note, dated 5/17/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 299 to 600 mg/dl. j. Skilled nursing visit note, dated 5/19/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 250 to 600 mg/dl. k. Skilled nursing visit note, dated 5/24/21 and 6/21/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 300 to 600 mg/dl. l. Skilled nursing visit note, dated 5/26/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 315 to 600 mg/dl. m. The update to the comprehensive assessment for recertification, dated 6/2/21, was completed by the nurse. The documentation stated the patient was diabetic and blood sugars were performed by the patient and the patient's blood sugar status was unknown (no glucometer, paper logs, visit reports, nor patient ability to report). The assessment included interventions for the skilled nurse to perform fasting blood sugar every visit using patient's glucometer to assess signs and symptoms of hypo/hyperglycemia or accuracy of reported blood sugars and the skilled nurse is to report fasting blood sugars greater than 250 milligrams (mg) per deciliter (dl) and random blood sugars greater than 300 mg/dl or less than 70 mg/dl to the physician. The nurse documented in the narrative note the patient has yet to check a blood sugar and states isn't going to, but last night's blood sugar was 261 and reported the patient's noncompliance. n. Skilled nursing visit notes, dated 6/7/21, 6/9/21, 6/14/21, 6/15/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 400 to 600 mg/dl. o. Skilled nursing visit note, dated 6/21/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 200 to 500 mg/dl. Interview on 7/14/21 at 12:00 PM with Staff B, RN Case Manager/Clinical Manager revealed no notification of blood sugars outside of reporting parameters as the physician was originally aware that the patient was refusing to take blood sugars and was tired of sticking fingers and did not care. The nurse did ask if the nurse could perform the finger stick and the patient would say no. The nurse did not report the blood sugars to the physician, as the doctor knew the patient was noncompliant and told the agency was told not to call them weekly. The clinical record lacked documentation of physician notification of the patient's continued high blood sugar readings. The above stated findings for Patient #2 was reported with the Administrator and Staff A, Administrative Assistant. The agency provided no additional information prior to the end of the survey.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, agency staff interview and patient/caregiver interview, the agency failed to effectively coordinate and oversee patient care provided by a licensed practical nurse (LPN) by a registered nurse (RN) for 3 of 3 sampled patients receiving care provided by an LPN (Patients #2, #3 and #6). The agency reported a current census of 128 patients at the time of the survey, including 31 patients receiving care from an LPN. Failure of the RN to effectively coordinate and oversee the LPN providing patient care placed agency patients at risk for safety and at risk for inadequate care. Findings include: According to the agency's undated policy, titled Monitoring Patient Care/Coordination of Care, effective interchange and reporting, as well as coordination of care will occur between the disciplines providing care. Communication regarding the patient's progress may occur through a formal case conference or as verbal/written communication among all staff members providing care. During agency staff interview on 7/12/2021 at 12:15 PM, Staff B, RN Clinical Manager reported she had worked for the agency for approximately one year, with the last 3-4 months functioning as Clinical Manager. She reported she carries a caseload of patients she is in charge of and the other 3 RNs and 1 LPN also carry a caseload of patients they are in charge of. Staff B, RN Clinical Manager, reported the Administrator/Owner, who is also an RN, did not carry a caseload and did not see patients. 1. Patient #3 had a start of care date of 2/1/2021 and was discharged from home health services on 4/20/2021. Clinical record review and applicable staff and patient interviews revealed the following: a. The Plans of Care, dated 2/1/2021 to 4/1/2021 and 4/2/2021 to 5/31/2021, included physician orders for skilled nursing services twice weekly. b. The clinical record included skilled nursing visits in the home, dated 2/6,9,16,19,23,25/2021; 3/2,4,9,11,16,18,23,25,30/2021; and 4/1,6,8,13,15,19/2021, completed by Staff F, LPN. c. During interview with the patient on 7/14/2021 at 8:45 AM, Patient #3 reported only having one staff (Staff F) visit him/her in the home during the entire episode of care. The patient did not recognize the name of the Administrator/Owner and denied ever having any contact with her. d. During agency staff interview on 7/14/2021 at 11:15 AM, the Administrator/RN of the agency reported Staff G, RN, directly assessed Patient #3 but, due to a personal conflict of interest, requested to have someone else be the primary RN. The Administrator/RN reported she used documentation collected by Staff G, RN, and telehealth (telephone only) assessment to complete the initial comprehensive assessment. The clinical record lacked any documentation completed by Staff G, RN, related to her direct assessment of Patient #3 at start of care. During agency staff interview on 7/14/2021 at 11:15 AM, the Administrator/RN of the agency reported she had not visited the patient to complete the discharge assessment as the patient "fired us". The Administrator/RN admitted she had never directly assessed Patient #3 between 2/1/2021 and 4/20/2021. She reported copying everything from the update to the assessment at the time of recertification, which was completed by Staff B, RN Clinical Manager. "So everything is the same as that." The Administrator/RN completed the initial comprehensive assessment at start of care and the update to the comprehensive assessment at discharge by telephone and did not visit the patient's home. e. During agency staff interview on 7/14/2021 at 11:50 AM, Staff B, RN Clinical Manager reported she had not visited Patient #3 in the home to perform the comprehensive assessment. She reported completing the comprehensive assessment by telehealth (by telephone only) interview. Staff B, RN Clinical Manager, denied being the primary RN for Patient #3 and indicated she had never seen the patient directly. The clinical record lacked documentation indicating Staff B, RN Clinical Manager had ever examined Patient #3 directly between 2/1/2021 and 4/20/2021. (All direct visits were made by Staff F, LPN) Staff B, RN Clinical Manager, completed the update to the comprehensive assessment at recertification by telephone and did not visit the patient's home. f. The patient's skilled nurse visit notes, dated 2/23/2021, 3/9/2021, 3/23/2021, documented the LPN administered an injection to Patient #3 during the home visit. The Plan of Care, dated 2/1/2021 to 4/1/2021, lacked identification of the medication or included physician orders for the LPN to administer the medication by injection. During agency staff interview on 7/14/2021 at 12:30 PM, Staff F, LPN, reported she administered the injections to the patient following a medication list left in the patient's home that instructed her to do so. g. The skilled nurse visit note, dated 2/25/2021 and authored by Staff F, LPN, reported the patient had new medications ordered. The nurse documented the medications in the note but did not document communication with the RN. The clinical record lacked a physician's order for the medication. The clinical record lacked any documentation of contact with the RN to report the new medications. h. During agency staff interview on 7/14/2021 at 1:55 PM, the Administrator/Owner reported Staff F, LPN, was the primary caregiver but she can't be the primary nurse "so I guess it would have had to have been me." The clinical record lacked any documentation of communication between the LPN and any RN related to the nurse administering the injections and the new medications as identified above. 2. Patient #6 had a start of care date of 10/12/2018 and was discharged from home health services on 5/24/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/30/2021 to 5/28/2021, included physician orders for skilled nurse visits once weekly. b. The clinical record lacked documentation of any skilled nursing visits during the weeks of 4/5/2021 to 4/10/2021; 4/11/2021 to 4/17/2021; 4/18/2021 to 4/24/2021; 4/25/2021 to 5/1/2021 and 5/2/2021 to 5/8/2021. The notes documented the nurse went to the patient's home on the day scheduled, finding the patient was not home and attempts to reach the patient were unsuccessful. c. The clinical record included missed visit notes for all of the above stated dates and documented the physician was notified; however, lacked identification of how the physician was notified. The clinical record lacked documentation of any telephone or written communication with the physician. The missed visit/fax log kept by the agency to corroborate physician notification of missed visits lacked any documentation of notification being sent to the physician reporting the above stated missed visits. d. The clinical record lacked documentation of any communication between the LPN and any RN, despite the patient going 5 weeks without any of the physician ordered skilled nursing visits. 3. Patient #2 had a start of care date of 12/9/2020 and a discharge date of 6/23/21. Clinical record review revealed: a. The Plans of Care, dated 4/8/2021 to 6/6/2021 and 6/7/21 to 8/5/21, documented the diagnoses of hypoglycemia. The Plan of Care ordered skilled nursing services 2 times per week and home health aide services 5 times per week. b. Nursing visits were only completed by a Registered Nurse (RN) for comprehensive assessments at start of care, recertification, and discharge. c. The update to the comprehensive assessment for recertification, dated 4/7/21, was completed over through telehealth (over the phone) by the Administrator/RN. The RN had never visited the patient in person prior to the telehealth visit. The documentation stated the patient was diagnosed with diabetes and no blood sugar ranges were specified and the patient was on insulin. d. Skilled nursing visit note, dated 4/14, 4/13, 4/19, 4/22/21 and completed by the licensed practical nurse (LPN), documented the patient had diabetes and was on insulin, no blood sugar ranges given and the patient was noncompliant with checking blood sugar reading. The visit note included interventions for the skilled nurse to perform fasting blood sugar every visit using patient's glucometer to assess signs and symptoms of hypo/hyperglycemia or accuracy of reported blood sugars and the skilled nurse is to report fasting blood sugars greater than 250 milligrams (mg) per deciliter (dl) or less than 60 mg/dl and random blood sugars greater than 300 mg/dl or less than 70 mg/dl to the physician. The narrative note documented the patient has not checked blood sugar today and has not been checking blood sugars or eating a diabetic diet. e. Skilled nursing visit note, dated 4/28/21 and completed by the LPN, documented the patient had diabetes and fasting blood sugar ranges of 90 to 200 mg/dl and random blood sugar ranges of 200 to 500 mg/dl and the patient's blood glucose last night was 411 mg/dl. f. The Licensed Visiting Nurse (LVN) supervisory visit note completed by the Administrator/RN, dated 5/3/21, documented supervision for the LPN, licensed practical nurse. g. Skilled nursing visit note, dated 5/5/21 and completed by the LPN, documented the patient had diabetes and blood sugars were performed by the patient and diabetic management of diet, exercise, and insulin use was administered by the patient. h. Skilled nursing visit note, dated 5/10/21 and completed by the LPN, documented the patient had diabetes and fasting blood sugar ranges of 100 to 400 mg/dl and random blood sugar ranges of 250 to 450 mg/dl. i. Skilled nursing visit note, dated 5/12/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 250 to 500 mg/dl and the patient does not check blood glucose reading in the morning. j. Skilled nursing visit note, dated 5/17/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 299 to 600 mg/dl. k. Skilled nursing visit note, dated 5/19/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 250 to 600 mg/dl. l. Skilled nursing visit note, dated 5/24/21 and 6/21/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 300 to 600 mg/dl. m. Skilled nursing visit note, dated 5/26/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 315 to 600 mg/dl. n. The Licensed Visiting Nurse (LVN) supervisory visit note completed by Case Manager/RN, dated 6/1/21, documented supervision for the LPN, licensed practical nurse. o. The update to the comprehensive assessment for recertification, dated 6/2/21 and completed by the nurse, documented the patient was diabetic and blood sugars were performed by the patient and the patient's blood sugar status was unknown (no glucometer, paper logs, visit reports, nor patient ability to report. The assessment included interventions for the skilled nurse to perform fasting blood sugar every visit using patient's glucometer to assess signs and symptoms of hypo/hyperglycemia or accuracy of reported blood sugars and the skilled nurse is to report fasting blood sugars greater than 250 milligrams (mg) per deciliter (dl) and random blood sugars greater than 300 mg/dl or less than 70 mg/dl to the physician. The nurse documented in the narrative note the patient has yet to check a blood sugar and states isn't going to, but last night's blood sugar was 261 and reported the patient's noncompliance. p. Skilled nursing visit notes, dated 6/7/21, 6/9/21, 6/14/21, 6/15/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 400 to 600 mg/dl. q. Skilled nursing visit note, dated 6/21/21 and completed by the LPN, documented the patient had diabetes and random blood sugar ranges of 200 to 500 mg/dl. r. The Licensed Visiting Nurse (LVN) supervisory visit note completed by Case Manager/RN, dated 6/23/21, documented supervision for the LPN, licensed practical nurse. Interview on 7/14/21 at 12:00 PM, with Staff B, RN Case Manager/Clinical Manager, revealed she was unsure what blood sugar readings have been as the LPN had been visiting the patient. The clinical record lacked documentation of communication between the LPN and RN of the patient's continued high blood sugar readings. The above findings for Patients #2, #3 and #6 were reviewed with the agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 4 sampled patients receiving home health aide services (Patients #2 and #7). The agency reported a current census of 128 patients at the time of the survey, including 77 who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: 1. Patient #2 had a start of care date of 12/9/2020 and a discharge date of 6/23/2021. Clinical record review revealed: a. The home health aide care plan included direction to the aide to perform the task of clean/file nails and shave the patient weekly. b. Home health aide visit notes, dated 5/3/21 and 5/7/21, documented completion of the tasks for clean/file nails and shave the patient as completed 2 times the week of 5/2/21. c. Home health aide visit notes, dated 5/11/21 and 5/12/21, documented completion of the tasks for clean/file nails and shave the patient as completed 2 times the week of 5/9/21. d. Home health aide visit notes, dated 5/18/21 and 5/19/21, documented completion of the tasks for clean/file nails as completed 2 times the week of 5/16/21. e. Home health aide visit notes, dated 6/1/21, and 6/2/21, documented completion of the task of shave the patient as completed 2 times the week of 6/30/21 and visit notes dated 6/1/21, 6/2/21, and 6/3/21, documented completion of the tasks for clean/file nails as completed 3 times the week of 6/30/21. f. Home health aide visit notes, dated 6/9/21 and 6/8/21, documented completion of the tasks for clean/file nails as completed 2 times the week of 6/6/21. The home health aide provided services at a frequency not included in the plan of care. 2. Patient #7 had a start of care date of 12/9/2020 and a discharge date of 6/23/2021. Clinical record review revealed: a. The home health aide care plan included direction to the aide to perform the task of clean/file nails weekly. b. Home health aide visit notes, dated 4/13/21 and 4/16/21, documented completion of the task to clean/file nails as completed 2 times the week of 4/11/21. c. Home health aide visit notes, dated 4/20/21 and 4/23/21, documented completion of the tasks for clean/file nails and shave the patient as completed 2 times the week of 4/18/21. The home health aide provided services at a frequency not included in the plan of care. The above findings for Patients # 2 and #7 were reviewed with agency Administrator and Staff A, Administrative Assistant. Agency staff provided no further information prior to the end of the survey.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on agency staff interview, the agency failed to failed do the following: 1) ensure the clinical manager assigned patients and agency staff (G960); and 2) ensure the clinical manager coordinated intake for patient referrals (G964). The systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 128 patients.

Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This ELEMENT is not met as evidenced by: Based on agency staff interview, the agency failed to ensure the Clinical Manager scheduled staff to make patient visits, allowing a non-clinical staff to assign staff to patients. The agency reported a current census of 128 patients. Delegating supervisory functions to non-clinical and/or non-qualified staff may result in inappropriate care provision and potentially result in inadequate services provision and/or injury. Findings include: During agency staff interview on 7/12/2021 at 12:15 PM, Staff B, Registered Nurse (RN) Clinical Manager reported Staff A, Administrative Assistant, does all scheduling of home health aide, licensed practical nurse (LPN) and RN visits to patients. During agency staff interview on 7/12/2021 at 12:32 PM, Staff A, Administrative Assistant reported she is not a clinical discipline. She did agree she does all scheduling of aides and nurses. During agency staff interview on 7/13/2021 at 10:00 AM, the Administrator/Owner reported Staff A, Administrative Assistant does all of the scheduling of home health aide, LPN and RN visits to patients. The Administrator reported she also is Clinical Manager by title but shares the title with Staff B, RN, who fills in when the Administrator is not in the office or available. The above stated findings were reviewed with the Administrator and Staff A, Administrative Assistant. The agency provided no additional information prior to the end of the survey.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on agency staff interview, the agency failed to ensure the Clinical Manager received and coordinated patient referrals, allowing a non-clinical staff to receive and participate in coordination of intake referrals. The agency reported a current census of 128 patients. Delegating supervisory functions to non-clinical and/or non-qualified staff may result in inappropriate care provision and potentially result in inadequate services provision and/or injury. Findings include: During agency staff interview on 7/12/2021 at 12:32 PM, Staff A, Administrative Assistant reported she is not a clinical discipline. During agency staff interview on 7/14/2021 at 10:15 AM, the Administrator/Owner reported Staff A, Administrative Assistant takes all referral information from the referring source- then discusses the information with the Administrator, then both the Administrator and Staff A, Administrative Assistant assign to a nurse as primary nurse for the patient. The above stated findings were reviewed with the Administrator and Staff A, Administrative Assistant. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 3 of 5 sampled patients with transfers/ discharges (Patients #2, #5, and #7). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: 1. Patient #2 had a start of care date of 12/9/2020 and discharged from the agency on 12/9/2020. Clinical record review revealed: a. A discharge assessment completed by the Administrator, dated 6/23/21, documented the patient was discharged and remained in the community with formal assistive services. The assessment further documented the discharge was per patient request. b. A home health discharge summary (auto-generated) completed by the Administrator, dated 6/23/21, lacked identification of who the summary was sent to and the date the summary was sent. c. An interim physician's order, dated 6/23/21, ordered to please discharge patient from the agency per patient request. d. Interview with agency Administrator on 7/31/21 at 3:06 PM, revealed she was unsure of where documentation of when the discharge summary was sent was located. Staff A, Administrative Assistant, came into the Administrator's office during the interview and informed the Administrator and surveyor the documentation is put into the electronic health record as a memo on a sticky note. The memo stated summary faxed 6/24/2021. The memo lacked identification of where/to whom the discharge summary was sent. The Administrator and Staff A, Administrative Assistant stated no documentation exists stating who/where the discharge summary was sent. Staff A, Administrative Assistant stated they always sent the summary to the patient's primary doctor. The discharge summary did not include physician notification of discharge summary. 2. Patient #7 had a start of care date of 11/23/2020 and discharged from the agency on 4/29/2021. Clinical record review revealed: a. A discharge assessment completed by the nurse, dated 4/29/21, documented the patient was discharged and remained in the community without formal assistive services. The assessment further documented the discharge was due to improved condition. b. A home health discharge summary (auto-generated) completed by the nurse, dated 4/29/21, lacked identification of who the summary was sent to and the date the summary was sent. c. An interim physician's order, dated 4/29/21, ordered to please discharge patient from the agency per patient request. d. The memo entered into the electronic health record stated summary faxed 4/30/2021. The memo lacked identification of where/to whom the discharge summary was sent. The discharge summary did not include physician notification of discharge summary. 3. Patient #5 had a start of care date of 12/29/2020 and was discharged from home health services on 4/22/2021. Clinical record review revealed the following: a. The transfer assessment, dated 2/2/2021, documented the patient was hospitalized on 2/2/2021. The update to the comprehensive assessment, dated 2/9/2021, documented the patient was discharged from the hospital on 2/8/2021. The transfer summary was not completed until 2/9/2021, 5 business days after the agency became aware of the transfer. b. The transfer assessment, dated 4/14/2021, documented the patient was hospitalized on 4/14/2021. The update to the comprehensive assessment, dated 4/19/2021, documented the patient was discharged from the hospital on 4/19/2021. The transfer summary was not completed until 4/19/2021, 3 business days after the agency became aware of the transfer. The above stated findings for Patient #2, #5 and #7 were reviewed with the Administrator and Staff A, Administrative Assistant. The agency provided no additional information prior to the end of the survey.

The Department of Inspections and Appeals conducted a COVID-19 Focused Infection Control Survey in conjunction with with a complaint survey, incident #95177-I from 2/8/21 through 2/22/21. The complaint survey found the following: During the survey, the surveyors identified three Immediate Jeopardy situations. The agency failed to do the following: 1) ensure agency staff investigated complaints made by patients or family, ensure staff investigated complaints related to care that failed to be furnished, failed to document the existence and resolution of complaints and failed to protect patients from further violations related to lack of care (CFR 484.50 refer to G0478, G0480, G0484, G0486); 2) ensure agency staff followed the plan of care in the delivery of services and alerted the physician to changes in the plan of care, ensure the plan of care accurately reflected the care and services the patient received and ensure the coordination of the delivery of care to meet the needs of the patients (CFR 484.60 refer to G0572, G0574 and G0608); 3) ensure home health aide agency staff provided home health aide services according the care plan (CFR 484.80 refer to G0800). The three Immediate Jeopardy situations were abated on 2/22/21 at 2:15 PM. The survey found the agency was operating out of compliance with the following Conditions of Participation: 1) Condition of Participation 42 CFR 484.50: Patient Rights (see G0406, G0434, G0440, G0462, G0464, G0468, G0470, G0478, G0480, G0484 and G0486); 2) Condition of Participation 42 CFR 484.60: Care Planning, Coordination and Quality of Care (see G0570, G0572, G574 and G608); 3) Condition of Participation 42 CFR 484.80: Home Health Aide Services (see G0750 and G0800) 4) Condition of Participation 42 CFR 484.110: Clinical Records (see G1008, G1014 and G1024) The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 2/22/21 and ending on 2/21/23.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to do the following: 1) ensure patients had the right to be informed about changes in the plan of care and refuse care in advance of or during treatment with respect to the disciplines providing care and frequency of visits (G0434); 2) ensure agency staff informed patients of the extent of financial obligation for services (G0440); 3) ensure agency staff had just cause to discharge agency patients (G0462); 4) ensure agency staff advised the patient and physician the agency was considering cause for discharge (G0464); 5) ensure agency staff provided contact information for other resources and providers at discharge for cause (G0468); 6) ensure agency staff documented the problem associated with cause for discharge and attempts to resolve the problem (G0470); 7) ensure agency staff investigated complaints made by patients or family (G0478); 8) ensure staff investigated complaints related to care agency staff failed to furnish or furnished inappropriately (G0480); 9) ensure agency staff documented the existence and resolution of complaints (G0484); and, 10) ensure agency staff took action to prevent further potential violations (G0486). The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 150 patients.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient, family and staff interview, the agency failed to ensure patients had the right to be informed about changes in the plan of care and refuse care in advance of or during treatment with respect to the disciplines providing care and frequency of visits for 13 of 24 patients sampled with home health aide services (Patients #1, #2, #4, #5, #9, #10, #11, #13, #14, #15, #17, #18 and #24). The agency reported 98 out of 150 patients received home health aide services at the time of the survey. Failure to ensure agency staff informed patients about changes in the plan of care and patients had the right to refuse care in advance of or during treatment with respect to disciplines providing care and frequency of visits resulted in agency patients not receiving care and services according to their plan of care and agreement for services. Findings include: Review of the agency's undated policy, titled Client Bill of Rights, identified the patient has the right to participate in, be informed about, and consent to or refuse care in advance of and during treatment with respect to care to be furnished based on comprehensive assessments, establishing and revising the Plan of Care, the disciplines that will furnish services, the frequency of visits, and any changes in care to be furnished. Review of the agency's undated policy, titled Missed Visit Policy, identified if the schedule is altered, agency staff shall provide information on alterations to the patient as soon as possible. In the event of an employee emergency or termination of employment, the agency will provide alternate, qualified staff to complete the required visits. If there is a missed visit, agency staff shall provide services as agreed upon by the patient and agency. Agency staff will coordinate with the patient or patient's authorized representative to reschedule a missed visit whenever possible. Review of the agency's undated policy, titled Implementing Care and Treatment, identified agency staff will notify the patient and/or caregiver prior to the scheduled visit if there is a change in the schedule of care. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: The Plan of Care (POC), dated 10/31/2020 to 12/29/2020, included orders for skilled nursing services 2 times per week and home health aide services 3 times per week. The clinical record included documentation of 3 missed home health aide visits the week of 12/20/2020, dated 12/21, 12/23 and 12/25/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. On 2/9/21 at 11:38 AM, during an interview, the patient reported he/she did not refuse any services the week of 12/20/2020. The patient reported the agency did not call or offer any services that week. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant explained they had one home health aide staff already on medical leave (Staff N, Home Health Aide) and then Staff I, home health aide, no longer worked for the agency effective 12/22/2020. Staff I worked with Patient #1. She reported having trouble scheduling home health aide services for Patient #1 and other patients also receiving home health aide services from Staff I. The Administrative Assistant reported the agency was short-staffed and they were unable to meet the needs of the patients. She explained the other home health aides were already "jamming visits" in and were unable to pick up extra visits. On 2/16/21 at 3:20 PM, during an interview, the Administrator/Clinical Manager reported the Administrative Assistant does the scheduling, but she was aware they had staffing issues for home health aide services. The Administrator explained for patients she completed missed visit notes on, "patient/family uncooperative" was just one of the choices and she realizes this was not the right choice for the reason for the missed visit. On 2/17/21 at 8:34 AM, during an interview, the Administrative Assistant reported she did notify the patients, that Staff I had provided services for, they would not be receiving home health aide services for a week. She explained she was not able to get a hold of some of the patients and not able to leave a message. She did not have any documentation of who she contacted and who she did not. The Administrative Assistant reported she did not know the staffing issues were going to last longer than a week and did not call any of the patients to notify them of this. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/20/2020. 2. Patient #2 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: The POC, dated 10/30/2020 to 12/28/2020 and 12/29 to 2/26/2020, included orders for skilled nursing services 1 time per week and home health aide services 2 times per week. The clinical record included documentation of 2 missed home health aide visits the week of 12/27/2020, dated 12/28 and 12/31, and 2 missed home health visits the week of 1/3/21, dated 1/4 and 1/7/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. On 2/9/21 at 9:25 AM, during an interview, the patient reported no one called or showed up to provide services the 2 weeks after Christmas. The patient reported he/she called the office to find out why he/she was not getting services. The patient explained he/she was told at this time the home health aide quit and they would be sending out a new girl. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant confirmed the patient did call about not having a home health aide after Staff I wasn't employed by the agency and requested another home health aide that had worked with the patient previously. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/27/2020 and 1/3/21. 3. Patient #4 had a start of care date of 9/21/2020. Review of the clinical record revealed the following: The POC, dated 11/20/2020 to 1/18/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. The clinical record included documentation of 1 missed home health aide visit the week of 12/20/2020, dated 12/24, and one missed home health aide visit the week of 12/27/2020, dated 12/31. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. On 2/9/21 at 10:03 AM, during an interview, the patient reported he/she did not refuse home health aide visits the weeks of Christmas and New Years. The patient reported staff were supposed to come and no one showed. The patient reported calling the office, because of no one showing up and was told about Staff I, at that time. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the weeks of 12/20 and 12/27/2020. 4. Patient #5 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: The POC, dated 11/9/2020 to 1/7/2021, included physician orders for skilled nursing and home health aide services 1 time per week. The clinical record included documentation of 1 missed home health aide visit the week of 12/20/2020, dated 12/25. The missed visit note included the following reason: cancellation of care by Staff J. On 2/9/21 at 10:56 AM, during an interview, the patient reported he/she was not offered services on Christmas or the week of 12/20/2020, and did not refuse a visit. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/20/2020. 5. Patient #9 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. A patient signed consent form for care and services, signed by the patient and agency staff on 11/9/2020, identified the agency planned to provide skilled nursing, home health aide and physical therapy services. b. The POC, dated 11/9/2020 to 1/7/2021 included orders for skilled nursing 1 time per week, home health aide services 2 times per week and physical therapy services 1 time the first week and then 2 times for 3 weeks. c. The home health aide care plan, dated 11/10/2020, included RN instructions to the home health aide to complete the following tasks: chair bath, tub bath, shower with chair, assist with dressing, lotion, shampoo hair, assist to toilet and incontinence care. d. The home health aide visit note completed by Staff L, Home Health Aide, dated 11/9/2020, included documentation the patient refused all personal cares. e A home health aide missed visit note completed by Staff L dated 11/12/2020, included the following documentation: "client was very rude and upset because she does not want a CNA" (certified nursing assistant or home health aide). f. The clinical record included documentation Staff I provided home health aide visits, dated 11/19 through 12/16/2020. g. The clinical record included documentation of missed home health aide visits, dated 11/12, 11/16 (patient refused/uncooperative), 12/21, 12/24, 12/28 and 12/31/2020, 1/4 and 1/7/21. h. Home Health Aide Supervisory visit notes, dated 11/30, 12/14 and 12/28/2020, included documentation Staff H, RN, had supervised the home health aide and documented the home health aide was following the care plan, arriving for assigned visits as scheduled, maintaining open communication with the patient and honoring patient rights. On 2/10/21 at 2:09 PM, during an interview, the patient reported she had not wanted home health aide or homemaker services. She reported she had been able to meet her own needs including showering independently. The patient told the nurse Staff H, RN, he/she did not want anyone else coming into the home. The patient denied receiving services from any agency staff person with the exception of Staff H, RN. On 2/16/21 at 12:17 PM, during an interview, Staff H, RN, reported the patient was confusing. The patient agreed to home health aide services at first due to lower back pain and safety concerns, but refused visits after the first 1 to 2 times. Staff H, RN, reported the patient agreed to accept the service when asked again. Staff H, RN, was not sure if the patient had let anyone provide home health aide services. Staff H, RN, reported she supervises the home health aides by asking the patient if the home health aide is following the care plan, reviews the tasks on the care plan with the patient to ensure the home health aide is following the plan, ask if the patient is satisfied, and, on occasion if the home health aide is new, review the home health aide's documentation. The patient repeatedly refused home health aide services and told agency staff the patient did not want the service. Agency staff failed to allow the patient the right to refuse care after originally agreeing to the service and continued to try to provide the service against the patient's wishes. 6. Patient #10 had a start of care date of 7/21/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/19/2020 to 11/17/2020 and 11/18/2020 to 1/16/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. A home health aide missed visit note, dated 12/24/2020, included documentation Staff J completed the form and documented the reason as "cancellation of care". c. A home health aide missed visit note, dated 12/29/2020, included documentation Staff J, Home Health Aide completed the form and documented the reason as "family/caregiver able to assist". d. The clinical record included documentation of 2 missed home health aide visits the week of 1/3/21, dated 1/5 and 1/7/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. On 2/10/21 at 9:02 AM, during an interview, the patient reported not having refused a home health aide visit unless it was for bad weather or a medical appointment. The patient denies having refused visits over the holidays or in early January 2021. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the weeks of 12/20 and 12/27/2020 and 1/3/21. 7. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: The POC, dated 10/9/2020 to 12/7/2020, included orders for home health aide services 2 times per week and skilled nursing services weekly. The POC, dated 12/8/2020 to 2/5/2021, included orders for skilled nursing and home health aide services 1 time per week. a. A patient signed consent form for care and services, signed by the patient and agency staff on 8/10/2020, identified the agency planned to provide skilled nursing, home health aide 2 times per week, occupational and physical therapy services. 1) A home health aide missed visit note, dated 10/9/2020, included documentation Staff I reported the reason for the missed visit as follows: "refused. client stated (the patient) wishes to cut down to one visit per week on Tuesdays as (the patient) doesn't have enough for us to do twice a week". 2) The clinical record included documentation of missed home health aide visits on Fridays, dated 10/16, 10/23, 10/30, 11/20, 11/27 and 12/4/2020, and documentation of 3 Fridays visits occurred, dated 11/6, 11/13 and 12/18/2020. On 2/10/21 at 11:30 AM, during an interview, the patient reported the patient told Staff O, Home Health Aide, the patient only wanted home health aide services one time per week. Agency staff ignored the patient's request to decrease home health aides services from 10/9 until 12/8/2020. The clinical record included documentation by Staff J of a missed home health aide visit the week of 12/20/2020, dated 12/25, due to a visit cancellation, and a missed home health aide visit the week of 12/27/2020, dated 1/1/21, due to a "hurt back". On 2/10/21 at 11:30 AM, during an interview, the patient reported he/she remembered Staff I. The patient was not sure if he/she refused any services over the Christmas and New Year's holiday, but did remember no one showing and up and calling the office with the concern of not receiving home health aide services. The patient reported when the he/she called the office to complain, the patient was told Staff I had quit and the agency would be sending someone else out. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the weeks of 12/20 and 12/27/2020. 8. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/30/2020 to 12/28/2020 and 12/29/2020 to 2/26/2021, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. b. The clinical record included documentation Staff I, provided home health aide visits, dated 10/9 to 11/27/2020, and then documented missed home health aide visits, dated 11/30, 12/2, 12/4, 12/7 and 12/9/2020. c. The clinical record included documentation Staff J, provided home health aide visits, dated 12/11 to 12/21/2020, and then documented missed visits, dated 12/23 and 12/25/2020 (cancellation of care), 12/28 and 12/30/2020 (doctor appointment) and 1/1/21 (black ice, staff couldn't leave house). The patient received one home health aide visit the week of 12/20 and no home health aide visits the week of 12/27/2020. On 2/10/21 at 12:48 PM, during an interview, the patient reported he/she had not refused or canceled any services the weeks of Christmas and New Year's (12/20 and 12/27/2020), and the patient denied agency staff had notified him/her that the agency would not be providing services as scheduled the weeks of Christmas and New Year's. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the weeks of 12/20 and 12/27/2020. 9. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: The POCs, dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. The home health aide care plan, dated 12/21/2020, included RN instructions to the home health aide to complete the following task: record the patient's last bowel movement. The week of 12/20/2020 included of 1 home health aide visit, dated 12/21, and one missed home health aide visit, dated 12/25 (reason- missed, other), completed by Staff J. On 2/10/21 at 3:15 PM, during an interview, the patient reported he/she was not notified the agency staff would not be providing services for as scheduled during the week of 12/20/2020. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the week of 12/20/2020. 10. Patient #15 had a start of care date of 9/17/2020. Review of the clinical record revealed the following: a. The POC, dated 11/16/2020 to 1/14/2021, included physician orders for skilled nursing and home health aide services 2 times per week. b. The clinical record included documentation the Administrator/Clinical Manager completed 2 missed home health aide visit notes the week of 12/20/2020, dated 12/22 and 12/25, due to the patient being uncooperative, and 2 missed home health aide visit notes the week of 12/27/2020, dated 12/29/2020 (no reason given) and 1/1/21. The Administrator/Clinical Manager documented the patient was uncooperative for a visit on 1/1/21. On 2/10/21 at 3:45 PM, during an interview, the patient reported he/she did not refuse home health aide services the weeks of Christmas (12/20/2020) and New Year's (12/27/2020), and the patient did not know why he/she did not get services those weeks. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the weeks of 12/20 and 12/27/2020. 11. Patient #17 had a start of care date of 11/30/2020 and transferred from agency services on 1/14/21. Review of the clinical record revealed the following: a. The POC, dated 11/30/2020 to 1/28/2021, included orders for skilled nursing services 2 times the first week and then 1 time per week for 8 weeks and an order for home health aide services 2 times per week. b. The week of 12/20/2020 included of 1 home health aide visit, dated 12/23, and one missed home health aide visit, dated 12/25 (reason- canceled), completed by Staff J. The week of 12/27/2020 included documentation of 1 home health aide visit, dated 12/30, and one missed home health aide visit, dated 1/1/21 (reason-canceled). The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the weeks of 12/20 and 12/27/2020. 12. Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: a. The POC, dated 12/15/2020 to 2/12/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The week of 12/20/2020 included of 2 missed home health aide visits, dated 12/23 and 12/25 (reason- canceled), completed by Staff J. The week of 12/27/2020 included documentation of 1 home health aide visit, dated 12/30, and one missed home health aide visit, dated 1/1/21 (reason-"complications with my back"). The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the weeks of 12/20 and 12/27/2020. 13. Patient #24 had a start of care date of 12/7/2020 and transferred from agency services on 12/29/2020. Review of the clinical record revealed the following: a. The POC, dated 12/7/2020 to 2/4/2021, included physician orders for skilled nursing 2 times per week and home health aide services 3 times per week for 8 weeks. b. The week of 12/20/2020 included documentation of 2 missed home health aide visits, dated 12/23 and 12/25. The missed home health aide visit note, dated 12/23, included documentation the Administrator/Clinical Manager completed the form and documented the reason for the missed visit as "patient/family uncooperative". The missed home health aide visit note, dated 12/25, included documentation Staff J completed the missed visit form and documented the reason as "canceled". The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the week of 12/20/2020. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 2 of 26 sampled patients (Patients #17 and #24). At the time of the survey, the agency reported a current census of 150 patients. Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: Review of the agency's undated policy, titled Client Bill of Rights, revealed the patient has the right to be advised of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before care is initiated and any changes in the information provided to the patient or patient representative, when they occur as soon as possible, in advance of the next home health visit. 1. Patient #17 had a start of care date of 11/30/2020 and transferred from agency services on 1/14/21. Review of the clinical record revealed the following: a. The patient's clinical record included a written consent form signed by the patient and home health agency staff, dated 11/30/2020. The document included options for Medicare, Medicaid, other insurance or private pay as potential payers. The document failed to include identification of which federally funded program or other insurance would be payer for home health services, how much the patient could expect to pay out of pocket for services and which services the home health agency would be providing. b. The Plan of Care (POC), dated 11/30/2020 to 1/28/2021, included orders for skilled nursing services 2 times the first week and then 1 time per week for 8 weeks, home health aide services 2 times per week and occupational therapy 1 time the first week. 2. Patient #24 had a start of care date of 12/7/2020 and transferred from agency services on 12/29/2020. Review of the clinical record revealed the following: a. The patient's clinical record included a written consent form signed by the patient's representative and home health agency staff, dated 12/7/2020. The document included options for Medicare, Medicaid, other insurance or private pay as potential payers. The document failed to include identification of which federally funded program or other insurance would be payer for home health services, how much the patient could expect to pay out of pocket for services and which services the home health agency would be providing. b. The POC, dated 12/7/2020 to 2/4/2021, included physician orders for skilled nursing 2 times per week, physical therapy 1 time the first week and then 2 times a week for 5 weeks and home health aide services 3 times per week for 8 weeks. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff discharged a patient with just cause and documented the behaviors and circumstances that warranted the discharge for 1 of 2 sampled discharged patients (Patient #18). The agency reported a current census of 150 patients at the time of survey. Failure to ensure agency staff have just cause and documented the behaviors and circumstances that warranted the discharge place agency patients at risk for being discharged with unmet needs and against the rights of the patient. Findings include: Review of the agency's undated policy, titled Patient Transfer/Agency Dissolution, identified agency staff will speak with the patient by telephone or in person to the ensure the patient's knowledge of discharge before the date of discharge at least 5 days in advance. Agency staff will assess each patient's discharge planning and/or continuing care needs on an ongoing basis and will involve the physician and patient in the planning process. Agency staff will notify the physician of intended discharges. Agency staff will discharge the patient when the patient meets discharge criteria and will provide appropriate discharge planning and notification per regulations. Agency staff may discharge the patient without 5 days notice upon the patient's request, if patient's medical needs require transfer, according to physician orders, if the patient fails to pay for services, for the protection of staff or a patient after the agency has made a documented reasonable effort to notify the patient, patient's family and physician of the agency's concern for staff or patient safety. Agency staff will educate the patient on aspects of post discharge continuity of care arrangements. Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 10/16/2020 to 12/14/2020 and 12/15/2020 to 2/12/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. The POCs included orders for the skilled nurse to do a complete physical assessment every visit with focus on high blood pressure, assess co-morbidities and other conditions, provide instruction on management of chronic obstructive pulmonary disease and on disease process related to cardiovascular function. b. The clinical record included documentation of skilled nursing visits, dated 10/5, 10/12, 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 12/11, 12/14, 12/21 and 12/28/2020. The clinical record included documentation of 1 missed skilled nursing visit, dated 11/30/2020. The clinical record lacked documentation of any difficulty agency nursing staff had with completing nursing visits. c. The update to the comprehensive assessment completed at discharge by the Administrator/Clinical Manager, dated 1/4/21, included documentation the patient's physician and the patient were in agreement to discharge the patient due to the patient's refusal of services. The discharge assessment also documented the agency was discharging the patient due to non-compliance with skilled nursing visits, the patient was able to verbalize who to follow up with post discharge, agency staff notified the patient's physician of the discharge and the discharge would be sent to the physician within 5 days. d. A physician order, dated 1/4/21 and time of 3:45 PM and effective 1/4/21, including the following order: please discharge patient from the agency due to the patient's non-compliance. The Administrative Assistant (who is not a nurse or clinician) signed the clinician section of the order on 1/21/21. The physician signed the order on 1/25/21. e. A Discharge Summary included documentation of a signature of completion by the Administrator/Clinical Manager, dated 1/22/21. f. The clinical record lacked any documentation with the physician or patient prior to the completion of the discharge assessment in regards to the agency planning on discharging the patient for cause related to non-compliance with skilled nursing visits. The clinical record lacked documentation the agency made efforts to resolve the problem with non-compliance and provided the patient with contact numbers for other community resources or providers that may be able to provide services to the patient. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, reported sometimes the patient would not answer the door and staff would have to go back several times in order to get the visit done. On 2/16/21 at 3:40 PM, during an interview, the Administrative Assistant reported for discharges prior to the end of the certification, the agency's usual process is to send notification to the physician and the physician signs the order and sends the order back. She reported sometimes she calls the physician. She thought there probably was not any documentation to show she had a discussion with the physician in regards to Patient #18 prior to the patient's discharge. On 2/17/21 at 8:34 AM, during an interview, the Administrative Assistant reported an inability to find documentation in the clinical record of contact made the physician prior to discharging the patient. On 2/17/21 at 8:43 AM, during an interview, the Administrator/Clinical Manager reported for discharges prior to the end of the certification, staff will send an order and discharge summary to the patient's physician. The physician will call if the physician disagrees with the discharge. Agency staff failed to establish just cause to discharge a patient for being uncooperative with accepting services and to document behaviors associated with the agency's reason for discharge. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff advised the patient and the patient's physician that agency staff were considering discharging the patient for cause prior to discharging the patient for 1 of 2 discharge patients sampled (Patient #18). The agency reported a current census of 150 patients at the time of survey. Failure to ensure agency staff advised the patient and the patient's physician that agency staff were considering discharging the patient for cause prior to discharging the patient placed agency patients at risk for being discharged with unmet needs and against the rights of the patient. Findings include: See G0462 Agency staff failed to advise the patient and patient's physician prior to discharging the patient that the agency was considering discharging the patient for cause related to non-compliance. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to show evidence of providing the patient with contact information for other resources or providers or may have been able to provide care for 1 of 2 discharge patients sampled (Patient #18). The agency reported a current census of 150 patients at the time of survey. Failure to ensure agency staff to provide the patient with contact information for other resources or providers or may have been able to provide care placed agency patients at risk for being discharged with unmet needs. Findings include: See G0462 Agency staff failed to show any evidence of providing the patient with contact information for other resources or providers or may have been able to provide care. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff documented problems and efforts to resolve problems related to the agency determining to discharge the patient for cause for 1 of 2 discharge patients sampled (Patient #18). The agency reported a current census of 150 patients at the time of survey. Failure to ensure agency staff documented problems and efforts to resolve problems related to the agency determining to discharge the patient for cause placed agency patients at risk for being discharged with unmet needs. Findings include: See G0462 Agency staff failed to document the existence of any problems with the patient being uncooperative or unwilling to except skilled nursing services. The agency failed to document any attempts at resolution of the problem. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency complaint log, patient, family/patient representative and staff interview, the agency failed to ensure the investigation complaints made by agency patients or the representative of the patient for 13 of 24 sampled patients (Patients #1, #2, #4, #5, #8, #11, #12, #13, #14, #16, #20, #23 and #25) who received home health aide services. The agency reported a census of 150 at the time of the survey including 98 patients receiving home health aide services. The agency had a total of 4 complaints documented since January 2020. Failure to investigate complaints made by agency patients or their representatives allows the problems to persist without being addressed and prevents the home health agency from critically evaluating the nature of the complaints, the investigation, and the resolution of the complaints. This allows problems to continue and worsen over time because patterns are not identified and addressed to improve patient care. Findings include: Review of the agency's undated policy, titled Client Bill of Rights, revealed the patient had a right to voice and report grievances or complaints regarding treatment or care that is delivered or fails to be delivered. Review of the agency's undated and untitled policy related to complaints revealed agency staff will investigate complaints made by a patient, family or guardian or a patient's health care provider. Agency staff will complete the investigation and documentation within 30 days of receipt of the complaint. Review of the agency's complaint log on 2/8/2020 revealed the following: Patient #1 complained on 10/19/2020 and 12/22/2020 that Staff I, Home Health Aide, was not showing up for visits. The complaint log lacked any documentation of investigation into the patient's complaints. The complaint log lacked documentation of complaints made by any other patients since 5/18/2020. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 9/1/2020 to 10/30/2020 and 10/31/2020 to 12/29/2020, included physician orders for skilled nursing services 2 times per week and home health aide services 3 times per week. b. The Home Health Aide Supervisory Visit notes, dated 10/26, 11/9, 11/23, 12/7 and 12/21/2020, included a signature of completion by Staff C, Licensed Practical Nurse (LPN), and all identified the home health aide was not arriving for visits as scheduled. On 2/8/21 at 9:10 AM, during an interview, the Administrative Assistant reported Patient #1 called and complained on 10/19/2020 about Staff I, Home Health Aide, not showing up. The Administrative Assistant explained she talked with Staff I about the concern. She reported the next complaint she received was from Patient #1 on 12/22/2020. The patient reported receiving a billing statement which identified the patient had been receiving home health aide services. The patient complained Staff I, Home Health Aide, had not been showing up and providing services. Effective 12/22/20, Staff I no longer worked for the agency. The Administrative Assistant denied receiving any complaints from the other 23 patients receiving home health aide services from Staff I. The Administrative Assistant reported Patient #1 was cognitively able to determine whether or not Home Health Aide staff provided home health aide services as scheduled. She reported Staff C, LPN, Staff D, RN, and Staff I were the only staff going into the patient's home while Staff I, Home Health Aide, had been assigned to provide home health aide services to the patient. On 2/8/21 at 12:05 PM, during an interview, the Administrator/Clinical Manager explained the Administrative Assistant reported to her about the missed home health aide visits for Patient #1 by Staff I, Home Health Aide. The Administrative Assistant did most of the investigation and called other patients who received services from Staff I, Home Health Aide. She did not know which patients the Administrative Assistant contacted, but did know they found out Patient #25 also reported not receiving home health aide services. She reported Patient #25 was now deceased. On 2/8/21 at 1:46 PM, during an interview, the Administrative Assistant confirmed the complaint log only included documentation of the date, patient, complaint and staff person involved in the complaint, not information on the investigation or resolution of the complaint. She explained they just started doing a complaint log in January of 2020 due to rarely getting complaints. She does not have any documentation of the investigations of any of the complaints. She did not have any documentation of which patients she called about Staff I, Home Health Aide. She explained most of the patients who received services from Staff I were not reliable or cognitively able to state whether or not Staff I provided services. On 2/9/21 at 11:38 AM, during an interview, the patient reported he/she called and spoke with the Administrative Assistant about Staff I, Home Health Aide, not showing up to provide care. The patient explained he/she told Staff C, LPN, several times Staff I was not showing up. The patient reported no one followed up with the patient on the complaints. On 2/9/21 at 1:27 PM, during an interview, Staff C, LPN, explained when she supervises home health aide services she asks if the home health aide is showing up as scheduled and if they are doing a good job; she does not review home health aide documentation. She reported all of the information in the Home Health Aide Supervisory visit notes came from interviews with Patient#1 and the patient complained every time of Staff I, Home Health Aide not showing to provide services. Staff C, LPN, reported she told Staff D, Registered Nurse (RN) one time and told the Administrative Assistant a couple times. She clarified and explained she had reported each time the patient complained. Agency staff failed to investigate multiple complaints made by Patient #1 between 10/19 and 12/22/2020. 2. Patient #2 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POC, dated 10/30/2020 to 12/28/2020 and 12/29 to 2/26/2020, included orders for skilled nursing services 1 time per week and home health aide services 2 times per week. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/26 through 12/21/2020. c. The clinical record included documentation of 2 missed home health aide visits the week of 12/27/2020, dated 12/28 and 12/31, and 2 missed home health visits the week of 1/3/21, dated 1/4 and 1/7/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. d. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/27/2020 and 1/3/21. See G434 Interview on 2/9/21 at 9:25 AM with Patient #2. See G434 Interview on 2/16/21 at 3:00 PM with Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 3. Patient #4 had a start of care date of 9/21/2020. Review of the clinical record revealed the following: a. The POC, dated 11/20/2020 to 1/18/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 11/17 to 12/22/2020. c. The clinical record included documentation of 1 missed home health aide visit the week of 12/20/2020, dated 12/24, and one missed home health aide visit the week of 12/27/2020, dated 12/31. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. See G434 Interview on 2/9/21 at 10:03 AM with patient #4. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 4. Patient #5 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. The POC, dated 11/9/2020 to 1/7/2021, included physician orders for skilled nursing and home health aide services 1 time per week. b. The clinical record included documentation of home health aide visits 1 time per week provided by Staff I, Home Health Aide, dated 11/13 to 12/18/2020. On 2/9/21 at 10:56 AM, during an interview, the patient reported Staff I, Home Health Aide, only showed up 1 time and never came back. The patient explained he/she called the office to complain, but the patient was not sure who the patient talked to about the complaint. The patient denied telling Staff E, RN, about any concerns with the home health aide. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, reported the patient never complained to her about the home health aide not showing up and the office never told her about any concerns. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported the patient never called the office to complain during the time the Staff I, Home Health Aide was providing services in the home. The Administrative Assistant explained the first time Staff K, Home Health Aide, showed up at the patient's home sometime after the Staff I no longer worked for the agency, the patient called into the office with concerns of not knowing what to do with Staff K, Home Health Aide. The patient told her that he/she had never had a home health aide before and did not know what to do with Staff K. The Administrative Assistant reported she did not realize at that time that the patient meant Staff I, Home Health Aide, had not been providing services. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 5. Patient #8 had a start of care date of 8/27/2020. Review of the clinical record revealed the following: a. The POC, dated 8/27/2020 to 10/25/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week. b. The POC, dated 10/26/2020 to 12/24/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week for 5 weeks, 1 time per week for 1 week, and no home health aide services the last 3 weeks of the certification period. c. The clinical record included documentation of completed and missed home health aide visits by Staff I, Home Health Aide, dated 10/14 to 11/30/2020. On 2/9/21 at 1:40 PM, during an interview, the patient reported Staff I, Home Health Aide, only showed up 2 times between October and the end of November 2020. The patient reported the 2 times Staff I, Home Health Aide, did show up, she only sat on the patient's couch and did not do anything. The patient explained after the first time the home health aide did not do anything, the patient told Staff D, RN. The patient reported telling Staff D, RN, again after Staff I, Home Health Aide, showed up the second time and did not do anything. The patient was not sure on the dates, but reported the patient knew he/she had told Staff D, RN, sometime prior to stopping home health aide services. d. An interim physician order, dated 12/2/2020, included orders to discontinue home health aide services per the patient's request. On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, reported she remembered the patient complaining Staff I, Home Health Aide, was not showing up and asked to discontinue services. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 6. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: a. The POC, dated 12/8/2020 to 2/5/2021, included orders for skilled nursing and home health aide services 1 time per week. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9 to 12/18/2020. c. The clinical record included documentation by Staff J, Home Health Aide, of a missed home health aide visit the week of 12/20/2020, dated 12/25, due to a visit cancellation, and a missed home health aide visit the week of 12/27/2020, dated 1/1/21, due to a "hurt back". On 2/10/21 at 11:30 AM, during an interview, the patient reported the patient remembered Staff I, Home Health Aide. The patient was not sure if he/she refused any services over the Christmas and New Year's holiday, but did remember no one showing and up and calling the office with the concern of not receiving home health aide services. The patient reported when he/she called the office to complain, the patient was told Staff I, Home Health Aide, had quit and the agency would be sending someone else out. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant described the patient as forgetful, and reported the patient did call the office about not getting services, but not until after Staff I, Home Health Aide, no longer worked for the agency. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 7. Patient #12 had a start of care date of 11/18/2020. Review of the clinical record revealed the following: a. The POC, dated 11/18/2020 to 1/16/2020, included orders for skilled nursing services 1 time per week and home health aide services 3 times per week. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 12/7 to 12/18/2020. On 2/11/21 at 8:58 AM, during an interview, the patient reported he/she did not remember Staff I, Home Health Aide, and did not remember if the patient had refused or missed services over the Christmas and New Year's holidays and the 2 weeks following. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported the patient did complain about staff not showing up a couple times or not finishing assigned tasks, but the patient was confused and not reliable in the patient's ability to report information. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 8. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/30/2020 to 12/28/2020 and 12/29/2020 to 2/26/2021, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9 to 11/27/2020, and then documented missed home health aide visits, dated 11/30, 12/2, 12/4, 12/7 and 12/9/2020. On 2/10/21 at 12:48 PM, interview with patient #13, reported he/she had not refused or canceled any services the end of November through 12/9/2020. The patient reported Staff I, Home Health Aide, would come to the patient's home, do one task and then get on her phone. The patient reported Staff I, Home Health Aide, never offered to assist the patient with bathing, dressing or applying lotion, and she never reminded the patient to take medications. The patient reported he/she told Staff I, Home Health Aide, to not come back after 4 weeks due to mishandling and haphazardly storing some glass Halloween decorations and almost ruining the patient's carpet. The patient reported he/she called the agency and complained about Staff I, Home Health Aide. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported the patient had complained to her about Staff I, Home Health Aide, not doing assigned tasks. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 9. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The home health aide care plan, dated 12/21/2020, included RN instructions to the home health aide to complete the following task: record the patient's last bowel movement. c. The clinical record included documentation Staff I, former Home Health Aide, provided home health aide visits, dated 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23, 12/7 and 12/11/2020, and with missed visits documented on 10/30, 11/27, 11/30 and 12/4/2020. On 2/10/21 at 3:15 PM, during an interview, the patient reported he/she remembered Staff I, Home Health Aide. The patient did not write down dates, but reported Staff I, Home Health Aide, came on Mondays and Fridays the times she did show up. The patient reported Staff I, Home Health Aide, never asked the patient about the patient's bowel movements. The patient reported none of the current staff have ever done this either. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, reported the patient had complained to her several times about Staff I, Home Health Aide, not showing or not doing tasks. Staff E reported she let the Administrative Assistant know when the patient complained and also sent a text to Staff I, Home Health Aide. Staff E, RN, reported the patient was cognitive and able to state the home health aide had not been coming to provide services. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported she was aware of Patient #14 complaining about Staff I, Home Health Aide, not coming to provide home health aide services, but explained the patient often falls asleep and does not answer the door. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 10. Patient #16 had a start of care date of 2/10/2020. Review of the clinical record revealed the following: a. The POC, dated 12/2/2020 to 1/30/2021, included physician orders for skilled nursing and home health aide services 2 times per week. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 12/4 to 12/21/2020. On 2/11/21 at 10:21 AM, during an interview, the patient reported Staff I, Home Health Aide, would say she was going to show up and then would not come. The patient clarified Staff I, Home Health Aide, did show up some of the times. The patient complained Staff I, Home Health Aide, would not do a good job when she did show up. The patient reported he/she complained to the office staff and requested a new home health aide some time around Christmas, but the patient was not sure of the exact date. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported the patient complained about the home health aide, but the patient was confused. The complaint log and patient clinical record lacked documentation of the existence and investigation of any complaint made by the patient. 11. Patient #20 had a start of care date of 10/16/2020 and discharged from agency services on 12/7/2020. Review of the clinical record revealed the following: a. The POC, dated 10/16/2020 to 12/14/2020, included physician orders for home health aide services 2 times per week and skilled nursing services 1 time the first week, 2 times per week for 2 weeks and 1 time per week for 6 weeks. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/20 to 12/5/2020. c. The Home Health Aide Supervisory visit notes, dated 10/29, 11/12 and 11/26/2020, included documentation Staff C, LPN, supervised the home health aide and documented the home health aide maintained open communication with the patient, family, caregiver, representative, arrived for assigned visits as scheduled, followed the patient's care plan and demonstrated competency with assigned tasks. On 2/11/21 at 11:29 AM, during an interview, a family member/caregiver reported not being the patient's primary caregiver, but frequently stayed with the patient during the day. The family member/caregiver explained the patient could not be left alone. The family member/caregiver reported problems with miscommunication with agency staff, no coordination of care delivery, missed home health aide visits. On 2/11/21 at 2:08 PM, during an interview, the patient's representative/family member, reported having documentation in a communication book made by the family of Staff I, Home Health Aide, showing up only 3 times, dated 10/20, 10/23 and 10/26/2020, and then not showing back up. The patient's representative/family member reported Staff C, LPN, never asked how home health aide services were going. On 2/16/21 at 12:03 PM, during an interview, Staff G, RN, reported she supervises home health aides either during a routine skilled nursing visit or during the update to the comprehensive assessment at the time of recertification. She explained sometimes the home health aide is present and she will ask the patient about concerns. She will check home health aide documentation at times, but usually the Administrator reviews the documentation. Staff G, RN, explained she went out on 12/7/2020 to do a "Recert" (update to the comprehensive assessment at the time of recertification), but ended up doing a discharge. She reported the family complained Staff I, Home Health Aide, had not been showing up to provide services at that time. Staff G, RN, explained Staff C, LPN, was the patient's primary nurse, so she passed the complaint onto Staff C, LPN, and the Administrative Assistant. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported she never received any complaints about Staff I, Home Health Aide. When asked how she supervised the home health aide, she reported she asked the patient or another family member. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported being unaware of any complaints made by the patient's family about Staff I, Home Health Aide. The complaint log and patient clinical record lacked documentation of the existence and investigation of any complaint made by the patient representative's. 12. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The POC, dated 10/13/2020 to 12/11/2020, included physician orders for skilled nursing and home health aide services 1 time per week. b. The POC, dated 12/12/2020 to 2/9/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. c. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 10/20 to 12/21/2020. On 2/16/21 at 11:15 AM, during an interview, the patient reported Staff I, Home Health Aide, only sat on the patient's couch and visited with the patient when she came. The patient reported Staff I, Home Health Aide, only showed up 2 times when she actually came into the patient's home. When she did come, she told the patient she was too busy to do any of the tasks. The patient reported there were a few times when Staff I, Home Health Aide, came to the door and told the patient she could not do services that day. The patient reported he/she complained about Staff I, Home Health Aide, to Staff E, RN, "all the time" and also called the agency's office to complain throughout the time Staff I, Home Health Aide, was supposed to be providing services. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, confirmed the patient was accurate and the patient had complained to her several times about Staff I, Home Health Aide. Staff E, RN, reported patient #23 would wait for Staff I, Home Health Aide, to show for scheduled visits and Staff I would never show up. Staff E, RN, reported she spoke with the Administrative Assistant about the patient's concerns, and the Administrative Assistant told Staff E, RN, she had other complaints about Staff I, Home Health Aide, and she would talk with Staff I. Staff E, RN, reported she followed up again with the Administrative Assistant, because the patient continued to complain. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported she knew the patient had been frustrated. She reported it had been hard to schedule the home health aide with the patient due to the patient's sleep schedule. The complaint log and patient clinical record lacked documentation of the existence and investigation of any complaint made by the patient. 13. Patient #25 had a start of care date of 8/26/2020 and transferred from agency services on 1/20/21. Review of the clinical record revealed the following: a. The POC, dated 10/25/2020 to 12/23/2020, included physician orders for skilled nursing and home health aide services 1 time per week. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 11/5 to 12/3/2020. c. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion by Staff C, LPN, dated 12/11/2020. Staff C, LPN, documented she supervised Staff I, Home Health Aide, and Staff I failed to maintain open communication with the patient, failed to arrive for assigned visits as scheduled, failed to follow the care plan for completion of assigned tasks, failed to competently complete assigned tasks and failed to honor patient rights. On 2/16/21 at 12:03 PM, during an interview, Staff G, RN, reported Staff C, LPN, did not pass on any concerns to her regarding Staff I, Home Health Aide. She explained that she was not the supervising RN, so Staff C, LPN, would have passed on any concerns to the supervising RN, identified as Staff D, RN. On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, explained the office staff does the scheduling of the home health aides and she did not know anything about missed home health aide visits. She denied Staff C, LPN, reported any concerns regarding Staff I, Home Health Aide. Staff D, RN, explained Staff C, LPN, does report everything to the Administrative Assistant and then the Administrative Assistant will pass on concerns to Staff D, RN. The Administrative Assistant did tell Staff D, RN, about concerns the patient reported in regards to Staff I, Home Health Aide, not showing or doing assigned tasks around the same time as Staff I's leaving employment with the agency. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported the patient told her that Staff I, Home Health Aide, had not been coming to provide home health aide services. Staff C, LPN, reported the patient complained prior to 12/17/2020, but she was unsure of dates. Staff C, LPN, reported the patient was unable to personal cares independently. The complaint log and patient clinical record lacked documentation of the existence and investigation of any complaint made by the patient. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency's complaint log, patient, family and representative and staff interviews, the agency failed to ensure agency staff investigated complaints of care that failed to be furnished for 13 of 24 sampled patients (Patients #1, #2, #4, #5, #8, #11, #12, #13, #14, #16, #20, #23 and #25) who received home health aide services. The agency reported a census of 150 at the time of the survey including 98 patients receiving home health aide services. The agency had a total of 4 complaints documented since January 2020. Failure to ensure agency staff investigated complaints of care that failed to be furnished placed agency patients resulted in agency patient's not receiving care and services to meet the needs of the patients. Findings include: Review of the agency's undated policy, titled Client Bill of Rights, revealed the patient had a right to voice and report grievances or complaints regarding treatment or care that is delivered or fails to be delivered. Review of the agency's undated and untitled policy related to complaints revealed agency staff will investigate complaints made by a patient, family or guardian or a patient's health care provider regarding treatment or care that was furnished or failed to be furnished. Agency staff will complete the investigation and documentation within 30 days of receipt of the complaint. Review of the agency's complaint log on 2/8/2020 revealed the following: Patient #1 complained on 10/19/2020 and 12/22/2020 that Staff I, former Home Health Aide, was not showing up for visits. The complaint log lacked any documentation of investigation into the patient's complaints of not receiving care. The complaint log lacked documentation of complaints made by any other patients since 5/18/2020. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 9/1/2020 to 10/30/2020 and 10/31/2020 to 12/29/2020. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The home health aide care plans, dated 9/1 and 10/31/2020, included registered nurse (RN) instructions to the home health aide to complete the following tasks: provide bed bath, assist with dressing, apply lotion to the skin, comb hair, oral care, clean/file nails, incontinence care, record last bowel movement, encourage fluids, turn and reposition and remind the patient to take medications every visit and then shampoo hair weekly. c. The update to the comprehensive assessment completed at the time of recertification, dated 10/29/2020, identified the patient had difficulty breathing with minimal exertion, was incontinent of bowel and bladder, limited range of motion in the lower extremities, was totally dependent on someone to assist with dressing and bathing and was bedfast. d. The Home Health Aide Supervisory Visit notes, dated 10/26, 11/9, 11/23, 12/7 and 12/21/2020, included a signature of completion by Staff C, Licensed Practical Nurse (LPN), and all identified the home health aide was not arriving for visits as scheduled. In addition, the notes, dated 11/23, 12/7 and 12/21, identified the home health aide was not providing care according to the care plan, not performing tasks competently and not honoring the patient's rights. See G478 Interview on 2/8/21 at 9:10 AM, with the Administrative Assistant. See G478 interview on 2/8/21 at 12:05 PM, with the Administrator/Clinical Manager. See G478 interview on 2/8/21 at 1:46 PM with the Administrative Assistant. See interview on 2/9/21 at 11:38 AM with Patient #1. See interview on 2/9/21 at 1:27 PM with Staff C, LPN. On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, explained she supervised home health aides by asking the Patients if the home health aide is showing up and following the care plan. She reported Staff C, LPN, never notified her of Patient #1's complaints. Staff D, RN, explained Staff C, LPN usually does not notify her, only the Administrative Assistant. She reported the Administrative Assistant did notify her about problems with Staff I, Home Health Aide, and Staff D, RN, spoke with Staff I about concerns just right before Staff I no longer worked for the agency. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported during the time period the agency scheduled Staff I, Home Health Aide, to provide cares to the patient, the patient's hygiene went downhill. The patient could not shower, and needed assistance with a bed bath. Staff C, LPN, reported the patient was obese and developed rashes in the skin folds. Agency staff failed to investigate multiple complaints of lack of care provided by Staff I, Home Health Aide, made by Patient #1 between 10/19 and 12/22/2020. 2. Patient #2 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POC, dated 10/30/2020 to 12/28/2020 and 12/29 to 2/26/2020, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/25/2020, identified the patient was a fall risk, had difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, oriented to person and place, required prompting if in stressful or new situations, required set-up assistance for grooming, toilet hygiene and dressing, but required assistance or supervision to bathe. c. The home health aide care plan, dated 12/25/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, encourage fluids and remind the patient to take medications. d. The clinical record included documentation of 2 missed home health aide visits the week of 12/27/2020, dated 12/28 and 12/31, and 2 missed home health visits the week of 1/3/21, dated 1/4 and 1/7/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. e. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/27/2020 and 1/3/21. See G478 Interview on 2/9/21 at 9:25 AM with patient #2. See G478 Interview on 2/16/21 at 3:00 PM with the Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 3. Patient #4 had a start of care date of 9/21/2020. Review of the clinical record revealed the following: a. The POC, dated 11/20/2020 to 1/18/2021, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The home health aide care plan, dated 11/16/2020, included RN instructions to the home health aide to complete the following tasks: tub bath, assist with dressing, encourage fluids, and remind the patient to take medications. c. The update to the comprehensive assessment completed at the time of recertification, dated 11/17/2020, identified the patient did not have a capable caregiver, the patient was blind, a fall risk, had difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, poor balance, required set up assistance for grooming and dressing and intermittent assistance with bathing (for supervision, encouragement, reminders, getting in and out of the shower and/or washing difficult to reach areas). d. The clinical record included documentation of 1 missed home health aide visit the week of 12/20/2020, dated 12/24, and one missed home health aide visit the week of 12/27/2020, dated 12/31. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. See G478 Interview on 2/9/21 at 10:03 AM with patient #4. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 4. Patient #5 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. The POC, dated 11/9/2020 to 1/7/2021, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The home health aide care plan, dated 11/16/2020, included RN instructions to the home health aide to remind the patient to take medications. c. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient was a fall risk, had dyspnea with moderate exertion, activity intolerance, incontinent of urine, oriented to person only, requires prompting under stressful or unfamiliar conditions, confused during day and evening but not constantly, poor balance, weakness, shuffling gait, required set up assistance for grooming, dressing and toilet hygiene and intermittent assistance with showering. On 2/9/21 at 10:56 AM, during an interview, the patient reported Staff I, Home Health Aide, only showed up 1 time and never came back. The patient explained he/she called the office to complain, but the patient was not sure who the patient talked to about the complaint. The patient was not sure when he/she called the office to complain, just some time after the home health aide did not show up. The patient denied telling Staff E, RN, about any concerns with the home health aide. See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 5. Patient #8 had a start of care date of 8/27/2020. Review of the clinical record revealed the following: a. The POC, dated 8/27/2020 to 10/25/2020, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The POC, dated 10/26/2020 to 12/24/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week for 5 weeks, 1 time per week for 1 week, and no home health aide services the last 3 weeks of the certification period. c. The comprehensive assessment completed at the start of care, dated 8/27/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 10/21/2020, identified the patient did not have a capable caregiver, was a fall risk, had difficulty breathing with minimal exertion, used 4 liters of oxygen per minute per nasal cannula, required prompts or became confused if new or stressful situations, forgetful, muscle weakness, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. d. The home health aide care plans, dated 8/28 and 10/23/2020, included RN instructions to the home health aide to complete the following tasks: shower, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. e. The clinical record included documentation of completed and missed home health aide visits by Staff I, Home Health Aide, dated 10/14 to 11/30/2020. Staff I, Home Health Aide, documented providing home health aide visits, dated 10/14, 10/19, 10/21, 11/2, 11/9, 11/11, 11/16, 11/18, 11/23, 11/25 and 11/30/2020, and she documented missed visits, dated 10/16 (due to only seeing patient on Mondays), 10/26, 10/28 and 11/4/2020. On 2/9/21 at 1:40 PM, during an interview, the patient reported Staff I, Home Health Aide, only showed up 2 times between October and the end of November 2020. The patient reported the 2 times Staff I, Home Health Aide, did show up, she only sat on the patient's couch and did not do anything. The patient explained after the first time the home health aide did not do anything, the patient told Staff D, RN. The patient reported telling Staff D, RN, again after Staff I, Home Health Aide, showed up the second time and did not do anything. The patient was not sure on the dates, but reported the patient knew he/she had told Staff D, RN, sometime prior to stopping home health aide services. f. An interim physician order, dated 12/2/2020, included orders to discontinue home health aide services per the patient's request. On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, reported she remembered the patient complaining Staff I, Home Health Aide, was not showing up and asked to discontinue services. g. The Home Health Aide Supervisory visit notes, dated 10/28, 11/11, 11/25 and 12/2/2020, included documentation Staff D, RN, completed the note and documented the home health aide followed the patient's care plan, arrived for visits as scheduled, maintains open communication with the patient and honored the patient's rights. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 6. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: a. The POC, dated 12/8/2020 to 2/5/2021, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The updates to the comprehensive assessment completed at the time of recertification, dated 10/5 and 12/7/2020, identified the following: a primary diagnosis of Parkinson's Disease, absence of a capable caregiver, fall risk, difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, oriented to person and place, forgetful, poor balance, muscle weakness, unsteady gait, required set up assistance with dressing, grooming and toilet hygiene and needed intermittent assistance with showering. c. The home health aide care plans, dated 10/6 and 12/8/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The clinical record included documentation by Staff J, Home Health Aide, of a missed home health aide visit the week of 12/20/2020, dated 12/25, due to a visit cancellation, and a missed home health aide visit the week of 12/27/2020, dated 1/1/21, due to a "hurt back". See G478 Interview on 2/10/21 at 11:30 AM with patient #11. See G478 on 2/16/21 at 3:00 PM, with the Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 7. Patient #12 had a start of care date of 11/18/2020. Review of the clinical record revealed the following: a. The POC, dated 11/18/2020 to 1/16/2020, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care, dated 11/18/2020, identified the patient did not have a capable caregiver, was a fall risk, oriented times three (person, place and time), but forgetful, required set up assistance for dressing, grooming and toilet hygiene and required intermittent assistance with bathing. c. The home health aide care plan, dated 11/23/2020, included RN instructions to the home health aide to complete the task of reminding the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 12/7 to 12/18/2020. See G478 interview on 2/11/21 at 8:58 AM with patient reported the patient #12. See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving home health aide services. 8. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/30/2020 to 12/28/2020 and 12/29/2020 to 2/26/2021, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/28/2020, identified the patient had a diagnosis of chronic obstructive pulmonary disease, was a fall risk, caregiver burnout, oriented to person and place, forgetful, difficulty breathing with minimal exertion, activity intolerance, urinary incontinence, poor balance, muscle weakness, required set up assistance with grooming and dressing and intermittent assistance with bathing. c. The home health aide care plans, dated 9/8 and 10/29/2020, included RN instructions to the home health aide to complete the following tasks: tub bath, assist with dressing, lotion and remind the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9 to 11/27/2020, and then documented missed home health aide visits, dated 11/30, 12/2, 12/4, 12/7 and 12/9/2020. See G478 Interview on 2/10/21 at 12:48 PM with patient #13. See G478 Interview on 2/16/21 at 2:25 PM with Staff C, LPN. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 9. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The updates to the comprehensive assessment completed at the time of recertification, dated 10/20 and 12/21/2020, identified the patient was at risk for falls, activity intolerance, poor balance, muscle weakness, unsteady gait, difficulty breathing with moderate exertion, bladder incontinence, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. c. The home health aide care plans, dated 8/24, 10/21 and 12/21/2020, included RN instructions to the home health aide to complete the following task: record the patient's last bowel movement. d. The clinical record included documentation Staff I,Home Health Aide, provided home health aide visits, dated 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23, 12/7 and 12/11/2020, and with missed visits documented on 10/30, 11/27, 11/30 and 12/4/2020. e. The Home Health Aide Supervisory visit note, dated 10/30/2020, completed by Staff Q LPN, included documentation she had supervised the home health aide and documented the home health aide was not maintaining open communication, not arriving for visits as scheduled, not following the care plan and not demonstrating competency in completing tasks. Staff Q documented this as an issue with how the patient wanted the house cleaned. f. The Home Health Aide Supervisory visit notes, dated 11/10, 12/8 and 12/21/2020, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication, arrived for visits as scheduled, followed the care plan and completed tasks competently. See G478 Interview on 2/10/21 at 3:15 PM with patient #14. See G478 Interview on 2/16/21 at 12:56 PM with Staff E, RN. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 10. Patient #16 had a start of care date of 2/10/2020. Review of the clinical record revealed the following: a. The POC, dated 12/2/2020 to 1/30/2021, included physician orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The update to the comprehensive assessment, dated 10/1/2020, identified the patient had alcoholic cirrhosis of the liver, muscle weakness and chronic obstructive pulmonary disease, was a fall risk, lack of caregiver/family support, difficulty breathing with minimal exertion, activity intolerance, incontinent of urine, oriented to person and place, forgetful, required assistance with grooming and bathing and set up assistance with dressing. c. The home health aide care plan, dated 12/1/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 12/4 to 12/21/2020. See G478 interview on 2/11/21 at 10:21 AM with patient #16. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 11. Patient #20 had a start of care date of 10/16/2020 and discharged from agency services on 12/7/2020. Review of the clinical record revealed the following: a. The POC, dated 10/16/2020 to 12/14/2020, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care, dated 10/16/2020, identified the patient required 24 hour supervision, had difficulty breathing with moderate exertion, activity intolerance, fatigue/weakness, oriented to person and place, forgetful, with increased episodes of severe confusion, impaired decision making, verbally disruptive, at risk for falls, poor balance, unsteady gait, required assistance for grooming, dressing, toilet hygiene and bathing. c. The home health aide care plan, dated 10/16/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, clean dentures, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/20 to 12/5/2020. e. The Home Health Aide Supervisory visit notes, dated 10/29, 11/12 and 11/26/2020, included documentation Staff C, LPN, supervised the home health aide and documented the home health aide maintained open communication with the patient, family, caregiver, representative, arrived for assigned visits as scheduled, followed the patient's care plan and demonstrated competency with assigned tasks. See G478 interview on 2/11/21 at 11:29 AM, with a family member/caregiver. See G478 interview on 2/11/21 at 2:08 PM, with the patient's representative/family member. See G478 interview on 2/16/21 at 12:03 PM with Staff G, RN. . See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient representative's complaint of not receiving care and services to meet the needs of the patient. 12. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The POC, dated 10/13/2020 to 12/11/2020, included physician orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The POC, dated 12/12/2020 to 2/9/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. c. The update to the comprehensive assessment completed at the time of recertification, dated 12/9/2020, identified the patient had diabetes, high blood pressure, heart failure, was a fall risk, absence of a capable caregiver, difficulty breathing with minimal exertion, oriented to person and place, forgetful, poor balance, muscle weakness, required set up assistance for grooming and dressing and intermittent assistance for bathing. d. The home health aide care plans, dated 10/13 and 12/9/2020, included RN instructions to the home health aide to complete the following personal care tasks: remind the patient to take medications. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 10/20 to 12/21/2020. f. The Home Health Aide Supervisory visit notes, dated 11/11, 11/25, 12/9 and 12/23, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication with the patient, arrived for assigned visits as scheduled, followed the care plan and demonstrated competency in assigned tasks. See G478 interview on 2/16/21 at 11:15 AM with patient #23. See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. 13. Patient #25 had a start of care date of 8/26/2020 and transferred from agency services on 1/20/21. Review of the clinical record revealed the following: a. The POC, dated 10/25/2020 to 12/23/2020, included physician orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care by Staff G, RN, dated 8/26/2020, identified the patient had respiratory failure, absence of a capable caregiver, difficulty breathing and used oxygen, was incontinent of urine, oriented to person and place, forgetful, a fall risk with poor balance, unsteady gait and muscle weakness, required set up assistance with grooming and bathing and intermittent assistance with showering. c. The home health aide care plan (titled homemaker care plan in the electronic system), dated 8/26 and 10/21/2020, included RN instructions to the home health aide to complete the following personal care tasks: record the patient's last bowel movement, meal set up, limit fluids, assist with ambulation, assist with transfer and remind the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 11/5 to 12/3/2020. e. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion by Staff C, LPN, dated 12/11/2020. Staff C, LPN, documented she supervised Staff I, Home Health Aide, and Staff I failed to maintain open communication with the patient, failed to arrive for assigned visits as scheduled, failed to follow the care plan for completion of assigned tasks, failed to competently complete assigned tasks and failed to honor patient rights. See G478 interview on 2/16/21 at 12:03 PM with Staff G, RN. See G478 interview on 2/16/21 at 12:32 PM with Staff D, RN. See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency complaint log, patient, family, representative and staff interview, the agency failed to ensure the documentation of complaints and the resolution of a complaints made by agency patients for 13 of 24 sampled patients (Patients #1, #2, #4, #5, #8, #11, #12, #13, #14, #16, #20, #23 and #25) who received home health aide services. The agency reported a census of 150 at the time of the survey including 98 patients receiving home health aide services. The agency had a total of 4 complaints documented since January 2020. Failure to document and maintain evidence of complaints and the resolution of the complaints allows the problems to persist without being addressed and prevents the home health agency from critically evaluating the nature of the complaints, the investigation, and the resolution of the complaints. This allows problems to continue and worsen over time because patterns are not identified and addressed to improve patient care. Findings include: See G0478 The agency failed to document both the existence of the complaints and the resolution of the complaints. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on clinical record review, review of the agency complaint log, agency policy review, patient, representative, family and staff interview, the agency failed to ensure staff took action to resolve complaints and prevent further violations for 6 of 24 sampled patients (Patients #1, #5, #8, #14, #23 and #25) receiving home health aide services. The agency reported a census of 150 at the time of the survey including 98 patients receiving home health aide services. The agency had a total of 4 complaints documented since January 2020. Failure to staff took action to resolve complaints placed agency patients at risk for not having identified complaints resolved in a satisfactory and timely manner and allowed for repeated offences to occur. Findings include: Review of the agency's undated policy, titled Client Bill of Rights, revealed the patient had a right to voice and report grievances or complaints regarding treatment or care that is delivered or fails to be delivered. Review of the agency's undated and untitled policy related to complaints revealed agency staff will investigate complaints made by a patient, family or guardian or a patient's health care provider. Agency staff will complete the investigation and documentation within 30 days of receipt of the complaint. Agency staff will involve the patient/caregiver and/or the patient's physician as appropriate to reach a resolution. Agency staff will document all actions taken and follow up performed on the complaint form, as well as report to management staff. Agency staff will communicate resolution and outcome information to the complainant. Review of the agency's complaint log on 2/8/2020 revealed the following: Patient #1 complained on 10/19/2020 and 12/22/2020 that Staff I, Home Health Aide, was not showing up for visits. The complaint log lacked any documentation of investigation into the patient's complaints of not receiving care. The complaint log lacked documentation of complaints made by any other patients since 5/18/2020. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 9/1/2020 to 10/30/2020 and 10/31/2020 to 12/29/2020, included physician orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The update to the comprehensive assessment completed at the time of recertification, dated 10/29/2020, identified the patient had difficulty breathing with minimal exertion, was incontinent of bowel and bladder, limited range of motion in the lower extremities, was totally dependent on someone to assist with dressing and bathing and was bedfast. c. The Home Health Aide Supervisory Visit notes, dated 10/26, 11/9, 11/23, 12/7 and 12/21/2020, included a signature of completion by Staff C, Licensed Practical Nurse (LPN), and all identified the home health aide was not arriving for visits as scheduled. In addition, the notes, dated 11/23, 12/7 and 12/21, identified the home health aide was not providing care according to the care plan, not performing tasks competently and not honoring the patient's rights. See G478 interview on 2/8/21 at 9:10 AM with the Administrative Assistant. See G478 interview on 2/8/21 at 12:05 PM with the Administrator/Clinical Manager. See G478 interview on 2/8/21 at 1:46 PM with the Administrative Assistant. See G478 interview on 2/9/21 at 11:38 AM with patient #1. See G478 interview on 2/9/21 at 1:27 PM with Staff C, LPN. On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, explained she supervised home health aides by asking the Patients if the home health aide is showing up and following the care plan. She reported Staff C, LPN, never notified her of Patient #1's complaints. She reported the Administrative Assistant did notify her about problems with Staff I, Home Health Aide, and Staff D, RN, spoke with Staff I about concerns just right before Staff I was no longer employed by the agency. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported during the time period the agency scheduled Staff I, Home Health Aide, to provide cares to the patient, the patient's hygiene went downhill. The patient could not shower, and needed assistance with a bed bath. Staff C, LPN, reported the patient was obese and developed rashes in the skin folds. Agency staff failed to take action to prevent further violations of lack of furnished care after the patient complained multiple times. 2. Patient #5 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. The POC, dated 11/9/2020 to 1/7/2021, included physician orders for skilled nursing and home health aide services 1 time per week. b. The home health aide care plan, dated 11/16/2020, included RN instructions to the home health aide to remind the patient to take medications. c. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient was a fall risk, had dyspnea with moderate exertion, activity intolerance, incontinent of urine, oriented to person only, requires prompting under stressful or unfamiliar conditions, confused during day and evening but not constantly, poor balance, weakness, shuffling gait, required set up assistance for grooming, dressing and toilet hygiene and intermittent assistance with showering (for supervision, encouragement, reminders, getting in and out of the shower and/or washing difficult to reach areas). d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits 1 time per week, dated 11/13 to 12/18/2020. See G478 interview on 2/9/21 at 10:56 AM with patient #5. See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. Agency staff failed to take action to prevent further violations of lack of furnished care after the patient complained to staff about lack of home health aide services. 3. Patient #8 had a start of care date of 8/27/2020. Review of the clinical record revealed the following: a. The POC, dated 8/27/2020 to 10/25/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week. b. The POC, dated 10/26/2020 to 12/24/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week for 5 weeks, 1 time per week for 1 week, and no home health aide services the last 3 weeks of the certification period. c. The comprehensive assessment completed at the start of care, dated 8/27/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 10/21/2020, identified the patient did not have a capable caregiver, was a fall risk, had difficulty breathing with minimal exertion, used 4 liters of oxygen per minute per nasal cannula, required prompts or became confused if new or stressful situations, forgetful, muscle weakness, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. d. The home health aide care plans, dated 8/28 and 10/23/2020, included RN instructions to the home health aide to complete the following tasks: shower, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. e. The clinical record included documentation of completed and missed home health aide visits by Staff I, Home Health Aide, dated 10/14 to 11/30/2020. Staff I, Home Health Aide, documented providing home health aide visits, dated 10/14, 10/19, 10/21, 11/2, 11/9, 11/11, 11/16, 11/18, 11/23, 11/25 and 11/30/2020, and she documented missed visits, dated 10/16 (due to only seeing patient on Mondays), 10/26, 10/28 and 11/4/2020. See G478 interview on 2/9/21 at 1:40 PM patient #8. f. An interim physician order, dated 12/2/2020, included orders to discontinue home health aide services per the patient's request. See G478 interview on 2/16/21 at 12:32 PM with Staff D, RN. g. The Home Health Aide Supervisory visit notes, dated 10/28, 11/11, 11/25 and 12/2/2020, included documentation Staff D, RN, completed the note and documented the home health aide followed the patient's care plan, arrived for visits as scheduled, maintains open communication with the patient and honored the patient's rights. Agency staff failed to take action to prevent further violations of lack of furnished care after the patient complained to staff about lack of home health aide services. 4. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The updates to the comprehensive assessment completed at the time of recertification, dated 10/20 and 12/21/2020, identified the patient was at risk for falls, activity intolerance, poor balance, muscle weakness, unsteady gait, difficulty breathing with moderate exertion, bladder incontinence, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. c. The home health aide care plans, dated 8/24, 10/21 and 12/21/2020, included RN instructions to the home health aide to complete the following task: record the patient's last bowel movement. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23, 12/7 and 12/11/2020, and with missed visits documented on 10/30, 11/27, 11/30 and 12/4/2020. e. The Home Health Aide Supervisory visit note, dated 10/30/2020, completed by Staff Q, LPN, included documentation she had supervised the home health aide and documented the home health aide was not maintaining open communication, not arriving for visits as scheduled, not following the care plan and not demonstrating competency in completing tasks. Staff Q documented this as an issue with how the patient wanted the house cleaned. f. The Home Health Aide Supervisory visit notes, dated 11/10, 12/8 and 12/21/2020, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication, arrived for visits as scheduled, followed the care plan and completed tasks competently. See G478 interview on 2/10/21 at 3:15 PM with patient #14. See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. Agency staff failed to take action to prevent further violations of lack of furnished care after the patient complained to staff multiple times about lack of home health aide services. 5. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The POC, dated 10/13/2020 to 12/11/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The POC, dated 12/12/2020 to 2/9/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. c. The update to the comprehensive assessment completed at the time of recertification, dated 12/9/2020, identified the patient had diabetes, high blood pressure, heart failure, was a fall risk, absence of a capable caregiver, difficulty breathing with minimal exertion, oriented to person and place, forgetful, poor balance, muscle weakness, required set up assistance for grooming and dressing and intermittent assistance for bathing. d. The home health aide care plans, dated 10/13 and 12/9/2020, included RN instructions to the home health aide to complete the following personal care tasks: remind the patient to take medications. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 10/20 to 12/21/2020. f. The Home Health Aide Supervisory visit notes, dated 11/11, 11/25, 12/9 and 12/23, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication with the patient, arrived for assigned visits as scheduled, followed the care plan and demonstrated competency in assigned tasks. See G478 interview on 2/16/21 at 11:15 AM with patient # 23. See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. Agency staff failed to take action to prevent further violations of lack of furnished care after the patient complained to staff multiple times about lack of home health aide services. 6. Patient #25 had a start of care date of 8/26/2020 and transferred from agency services on 1/20/21. Review of the clinical record revealed the following: a. The POCs, dated 8/26/2020 to 10/24/2020 and 10/25/2020 to 12/23/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care by Staff G, RN, dated 8/26/2020, identified the patient had respiratory failure, absence of a capable caregiver, difficulty breathing and used oxygen, was incontinent of urine, oriented to person and place, forgetful, a fall risk with poor balance, unsteady gait and muscle weakness, required set up assistance with grooming and bathing and intermittent assistance with showering. c. The home health aide care plan (titled homemaker care plan in the electronic system), dated 8/26 and 10/21/2020, included RN instructions to the home health aide to complete the following personal care tasks: record the patient's last bowel movement, meal set up, limit fluids, assist with ambulation, assist with transfer and remind the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 11/5 to 12/3/2020. Staff M, Home Health Aide, had provided home health aide services after Staff I, Home Health Aide, starting on 12/10/2020. e. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion by Staff C, LPN, dated 12/11/2020. Staff C, LPN, documented she supervised Staff I, Home Health Aide, and Staff I failed to maintain open communication with the patient, failed to arrive for assigned visits as scheduled, failed to follow the care plan for completion of assigned tasks, failed to competently complete assigned tasks and failed to honor patient rights. See G478 interview on 2/16/21 at 12:03 PM with Staff G, RN. See G478 interview on 2/16/21 at 12:32 PM with Staff D, RN. See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. The complaint log and clinical record lacked any documentation of an existence, investigation or resolution of the patient's complaints of not receiving care and services to meet the needs of the patient. Agency staff were aware of the patient's complaints for an indeterminate amount of time and placed the patient in a position to suffer further violations of lack of care. The patient died prior to this survey. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review, patient and family interview and agency staff interview, the agency: 1) failed to ensure agency staff followed the plan of care in the delivery of services and alerted the physician to changes in the plan of care (G0572); 2) failed to ensure the Plan of Care accurately reflected care, treatment and services provided to the patient (G0574); and, 3) failed to ensure agency staff provided coordination in the delivery of care to meet the needs of the patients (G0608). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 150 patients.

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 clinical record review, agency policy review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a doctor of medicine, osteopathy or podiatry or notify the physician of the need to vary from the physician ordered Plan for Care for 9 of 24 sampled patients with home health aide services (Patients #7, #8, #9, #11, #13, #14, #16, #18 and #23). The agency reported 98 out of 150 patients received home health aide services at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: Review of the agency's undated policy, titled Plan of Care, revealed agency staff develop the Plan of Care (POC) in consultation with staff, the patient, the physician and other providers involved in the patient's care based on patient assessment information. Modifications to the POC are indicated by changes in orders. Review of the agency's undated policy, titled Implementing Care and Treatment, identified agency staff will provide care and treatment within the frequency parameters established on the POC. Agency staff will notify the physician when the provision of care/treatment can not be implemented as established on the POC. Review of the agency's undated policy, titled Missed Visit Policy, identified if the schedule is altered, agency staff shall provide information on alterations to the patient as soon as possible. In the event of an employee emergency or termination of employment, the agency will provide alternate, qualified staff to complete the required visits. If there is a missed visit, agency staff shall provide services as agreed upon by the patient and agency. Agency staff will coordinate with the patient or patient's authorized representative to reschedule a missed visit whenever possible. 1. Patient #7 had a start of care date of 9/28/2020. Review of the clinical record revealed the following: a. The POC, dated 9/28/2020 to 11/26/2020, included orders for home health aide services 2 times per week. b. The comprehensive assessment completed at the start of care, dated 9/28/2020, identified the patient was a fall risk, had a lack of caregiver/family support, a fall risk, incontinent of urine, poor balance, muscle weakness, difficulty breathing with moderate exertion, required set up assistance with grooming and intermittent assistance with bathing. c. The home health aide care plan, dated 9/30/2020, included RN instructions to the home health aide to complete the following tasks personal care tasks: shower, assist with dressing, apply lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfers, remind the patient to take medications every visit, and then clean/file nails and shave weekly. d. The home health aide visit notes, dated 10/8 and 10/22/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks. Due to agency staff only providing homemaker services on 10/8 and 10/22/2020, agency staff did not provide a home health aide service, making both of these visits missed home health aide visits. The week of 10/4/2020 had 2 home health aide missed visits, dated 10/6 and 10/8, with no physician notification of the second missed visit on 10/8. The week of 10/18/2020 included documentation of one home health aide visit, dated 10/21, and one missed visit, dated 10/22. Agency staff failed to notify the physician of the missed home health aide visit on 10/22/2020. 2. Patient #8 had a start of care date of 8/27/2020. Review of the clinical record revealed the following: a. The POC, dated 8/27/2020 to 10/25/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week. b. The comprehensive assessment completed at the start of care, dated 8/27/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 10/21/2020, identified the patient did not have a capable caregiver, was a fall risk, had difficulty breathing with minimal exertion, used 4 liters of oxygen per minute per nasal cannula, required prompts or became confused if new or stressful situations, forgetful, muscle weakness, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. c. The home health aide care plan, dated 8/28/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The home health aide visit notes, dated 10/19 and 10/21/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks. Due to agency staff only providing homemaker services on 10/19 and 10/21/2020, agency staff did not provide a home health aide service, making both of these visits missed home health aide visits. The week of 10/18/2020, included documentation of 2 missed home health aide visits, dated 10/19 and and 10/21. Agency staff failed to notify the physician of the missed home health aide visits. 3. Patient #9 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. A patient signed consent form for care and services, signed by the patient and agency staff on 11/9/2020, identified the agency planned to provide skilled nursing, home health aide and physical therapy services. b. The POC, dated 11/9/2020 to 1/7/2021, identified a diagnosis of fracture of the first lumbar vertebra and included orders for skilled nursing 1 time per week, home health aide services 2 times per week and physical therapy services 1 time the first week and then 2 times for 3 weeks. c. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient suffered from lower back pain with an intensity of 3 to 10 (with 10 the worst) all the time, occasional incontinence, at risk for falls, oriented to person and place, forgetful, but lacked a memory deficit, confused in new or complex situations, required assistance with set up for grooming and upper body dressing, dependent on assistance for lower body dressing, unable to shower without assistance, unable to maintain toilet hygiene and transfer without assistance and chairfast, but able to wheel self independently. d. The home health aide care plan, dated 11/10/2020, included RN instructions to the home health aide to complete the following tasks: chair bath, tub bath, shower with chair, assist with dressing, lotion, shampoo hair, assist to toilet and incontinence care. e. The home health aide visit notes, dated 11/9, 11/19, 11/23, 11/25, 11/30, 12/3, 12/7, 12/10 (documented on two different days and 2 different notes for the same day) and 12/16/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks. Due to agency staff providing only homemaker services, agency staff missed providing home health aide service on the above dates. f. The week of 11/9/2020 included documentation of 1 missed home health aide visit notification to the physician, dated 11/12, but lacked a missed home health aide visit notification to the physician for the visit on 11/9. g. The week of 11/15/2020 included documentation of 1 missed home health aide visit notification to the physician, dated 11/16, but lacked a missed home health aide visit notification to the physician for the visit on 11/19. h. The weeks of 11/22, 11/29, 12/6 and 12/13/2020 failed to include documentation of missed visit notification to the physician for home health aide visit notes, dated 11/23, 11/25, 11/30, 12/3, 12/7, 12/10 and 12/16. 4. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: a. The POC, dated 10/9/2020 to 12/7/2020, included orders for home health aide services 2 times per week and skilled nursing services weekly. b. The update to the comprehensive assessment completed at the time of recertification, dated 10/5/2020, identified the following: a primary diagnosis of Parkinson's Disease, absence of a capable caregiver, fall risk, difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, oriented to person and place, forgetful, poor balance, muscle weakness, unsteady gait, required set up assistance with dressing, grooming and toilet hygiene and needed intermittent assistance with showering. c. The home health aide care plan, dated 10/6/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The home health aide visit note, dated 10/20/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks. Due to agency staff only providing homemaker services on 10/20/2020, agency staff did not provide a home health aide service, making this a missed home health aide visit. The clinical record included documentation of physician notification of 1 missed home health aide visit the week of 10/18/2020, dated 10/23, but lacked documentation of a second missed visit note and physician notification for the same week. 5. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POC, dated 8/31/2020 to 10/29/2020, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. b. An interim physician order, dated 9/21/2020, included an order to increase home health aide services to 3 times per week. c. The POC, dated 10/30/2020 to 12/28/2020, included an order for home health aide services 1 time the first week and then 2 times per week. d. The update to the comprehensive assessment completed at the time of recertification, dated 12/28/2020, identified the patient had a diagnosis of chronic obstructive pulmonary disease, was a fall risk, caregiver burnout, oriented to person and place, forgetful, difficulty breathing with minimal exertion, activity intolerance, urinary incontinence, poor balance, muscle weakness, required set up assistance with grooming and dressing and intermittent assistance with bathing. e. The home health aide care plans, dated 9/8 and 10/29/2020, included RN instructions to the home health aide to complete the following personal care tasks: tub bath, assist with dressing, lotion and remind the patient to take medications. f. The home health aide visit notes, dated 10/9, 10/12, 10/14, 10/19, 10/21, 10/23, 10/26 and 10/30/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks which made these all missed home health aide visits. g. The week of 10/4/2020, included documentation of a home health visit, dated 10/5, a missed home health aide visit with physician notification on 10/7, and a missed home home health aide visit with no physician notification, dated 10/9. The week of 10/11/2020, included documentation of 2 missed home health aide visits with no physician notification, dated 10/12 and 10/14. The week of 10/18/2020 included documentation of 3 missed home health aide visits with no physician notification, dated 10/19, 10/21 and 10/23. The week of 10/25, included documentation of 2 missed home health aide visits with no physician notification, dated 10/26 and 10/30. h. The week of 11/22/2020, included documentation of 3 home health aide visits, dated 11/23, 11/25 and 11/27. The POC included orders for only 2 home health aide visits per week. The clinical record lacked documentation of an order for an extra home health aide visit the week of 11/22. i. The week of 12/13/2020, included documentation of 3 home health aide visits, dated 12/14, 12/16 and 12/18. The POC included orders for only 2 home health aide visits per week. The clinical record lacked documentation of an order for an extra home health aide visit the week of 12/13. On 2/22/21 at 3:30 PM, during an interview, the Administrative Assistant reported she checked the computer and hard copy of the medical chart and confirmed the home health aide provided an extra home health aide visit without an order the weeks of 11/22 and 12/13/2020. 6. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The updates to the comprehensive assessment completed at the time of recertification, dated 10/20 and 12/21/2020, identified the patient was at risk for falls, activity intolerance, poor balance, muscle weakness, unsteady gait, difficulty breathing with moderate exertion, bladder incontinence, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. c. The home health aide care plans, dated 8/24, 10/21 and 12/21/2020, included RN instructions to the home health aide to complete the following personal care task: record the patient's last bowel movement. d. The home health aide visits, dated 10/9, 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23, 12/11, 12/14 and 12/21/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed the assigned personal care task. All of these visits were missed home health aide visits since the home health aides failed to provide any personal care. e. The home health aide visits the weeks of 10/4, 10/25, 11/22, 12/13 and 12/20/2020, included documentation of one missed home health aide visit with physician notification and 1 missed home health aide visit without physician notification, dated 10/9, 10/26, 11/23, 12/14 and 12/21/2020. f. The home health aide visits the weeks of 10/11, 10/18, 11/1, 11/8 and 11/15/2020, included documentation of 2 missed home health aide visits with no physician notification, dated 10/12, 10/16, 10/19, 10/23, 11/2, 11/6, 11/9, 11/13, 11/16 and 11/20/2020. g. The home health aide visits the week of 12/6/2020, included documentation of signed visit, dated 12/7, but the visit note lacked documentation of the completion of any tasks. A second visit note for the week, dated 12/11, included documentation of the completion of only homemaker tasks. The clinical record lacked documentation of physician notification of the 2 missed home health aide visits for the week of 12/6. 7. Patient #16 had a start of care date of 2/10/2020. Review of the clinical record revealed the following: a. The POC, dated 10/3/2020 to 12/1/2020, included a physician order for skilled nursing services 2 times the first week and then 1 time a week for 8 weeks. b. The week of 10/11/2020 included documentation of 2 skilled nursing visits, dated 10/13 and 10/15. The clinical record lacked documentation of a physician order for the extra skilled nursing visit. On 2/22/21 at 3:41 PM, during an interview, the Administrative Assistant explained the electronic system did not automatically schedule visits; a staff person has to manually enter in the schedule. She looked in the clinical record and confirmed agency staff did not have an order for the extra skilled nursing visit. She thought it was a scheduler problem. 8. Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: a. The POC, dated 8/17/2020 to 10/15/2020, included physician orders for home health aide services 2 times per week. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/14/2020, identified the patient had chronic kidney failure, atrial fibrillation, did not have a capable caregiver, was short of breath with moderate exertion, had fatigue and weakness, incontinent of urine, at risk for falls, poor balance, unsteady gait, oriented to person and place, forgetful, required set up assistance with grooming and dressing and intermittent assistance with bathing. c. The home health aide care plan, dated 8/17/2020, included RN instructions to the home health aide to complete the following personal care tasks: limit fluids and remind the patient to take medications. d. The home health aide visit note, dated 10/9/2020, included documentation the home health aide completed homemaker tasks, but none of the assigned personal care tasks. Due to a lack of completion of personal cares, the visit was a missed home health aide visit. e. The week of 10/4/2020, included documentation of 1 missed home health aide visit with physician notification, dated 10/7, and 1 missed home health aide visit without physician notification, dated 10/9. 9. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The POC, dated 10/13/2020 to 12/11/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/9/2020, identified the patient had diabetes, high blood pressure, heart failure, was a fall risk, absence of a capable caregiver, difficulty breathing with minimal exertion, oriented to person and place, forgetful, poor balance, muscle weakness, required set up assistance for grooming and dressing and intermittent assistance for bathing. c. The home health aide care plans, dated 10/13/2020, included RN instructions to the home health aide to complete the following personal care tasks: remind the patient to take medications. d. The clinical record included documentation of 2 home health aide visits the week of 11/1/2020, dated 11/3 and 11/6, the week of 11/15/2020, dated 11/18 and 11/20, the week of 11/29/2020, dated 11/30 and 12/2, and the week of 12/6/2020, dated 12/7 and 12/9. The clinical record lacked documentation of a physician order for the extra home health aide visit the agency staff provided the weeks of 11/1, 11/15, 11/29 and 12/6/2020. e. The week of 11/8/2020 included documentation of 3 home health aide visits, dated 11/9, 11/11 and 11/13. The clinical record lacked documentation of a physician order for the 2 extra home health aide visits. On 2/22/21 at 3:47 PM, during an interview, the Administrative Assistant explained she did not know if the extra home health aide visits occurred. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 5 of 16 sampled patients (Patients #3, #6, #17, 24 and #26). The agency reported a current census of 150 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: Review of the agency's undated policy, titled Plan of Care, revealed agency staff develop the Plan of Care (POC) in consultation with staff, the patient, the physician and other providers involved in the patient's care based on patient assessment information. The POC will include specific procedures and treatments to be performed including amount, frequency and duration. 1. Patient #3 had a start of care date of 7/1/19. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included physician orders for home health aide services one time per week to assist with personal cares and activities of daily living as indicated on functional and physical status impeding self-care. b. The home health aide care plans, dated 10/21 and 12/22/2020, included registered nurse (RN) instructions for the home health aide to complete the following tasks: make bed, change linen, tidy bathroom, tidy bedroom, tidy kitchen, tidy patient's area, vacuum and take out trash. None of the assigned tasks related to performing personal cares which are a requirement for home health aide services. The assigned tasks were related to homemaker services. The POCs inaccurately identified the patient needed and would receive home health aide services. 2. Patient #6 had a start of care date of 8/4/2020. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 8/4/2020 to 10/2/2020, 10/3/2020 to 12/1/2020, 12/2/2020 to 1/30/2021, 1/31/2021 to 3/31/2021, included physician orders for home health aide services two times per week to assist with personal cares and activities of daily living as indicated on functional and physical status impeding self-care. b. The home health aide care plans, dated 8/6, 10/4 and 12/3/2020 and 1/28/21, included registered nurse (RN) instructions for the home health aide to complete the following tasks: make bed, change linen, tidy bathroom, tidy bedroom, tidy kitchen, tidy patient's area, vacuum, shopping and take out trash. None of the assigned tasks related to performing personal cares which are a requirement for home health aide services. The assigned tasks were related to homemaker services. The POCs inaccurately identified the patient needed and would receive home health aide services. 3. Patient #17 had a start of care date of 11/30/2020 and transferred from agency services on 1/14/21. Review of the clinical record revealed the following: a. The POC, dated 11/30/2020 to 1/28/2021, included orders for skilled nursing services 2 times the first week and then 1 time per week for 8 weeks, home health aide services 2 times per week and occupational therapy 1 time the first week. The POC also included the following order: physical therapy (PT) to assess functional status, home environment to eliminate structural barriers, improve safety and functional independence. PT to assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/coordination and transfers. PT to establish home exercise program and plan of care as approved by physician. The POC lacked a scope and frequency for PT services. b. The clinical record lacked documentation the patient received PT services. On 2/22/21 at 1:15 PM, during an interview, the Administrative Assistant reported it was a mistake on the POC, and the patient was never supposed to receive PT services. 4. Patient #24 had a start of care date of 12/7/2020 and transferred from agency services on 12/29/2020. Review of the clinical record revealed the following: a. The POC, dated 12/7/2020 to 2/4/2021, included physician orders for skilled nursing 2 times per week, physical therapy 1 time the first week and then 2 times a week for 5 weeks and home health aide services 3 times per week for 8 weeks. The POC also included the following order: occupational therapy (OT) to assess functional status, home environment to eliminate structural barriers, improve safety, need for home modifications to promote functional independence. OT to assess rehabilitation potential and determine need for activities of daily living (ADL) training, safety precautions, pain management, strengthening/conditioning exercise. OT to establish home exercise program and plan of care as approved by physician. The POC lacked a scope and frequency for OT services. b. The clinical record lacked documentation the patient received OT services. On 2/22/21 at 1:15 PM, during an interview, the Administrative Assistant reported it was a mistake on the POC, and the patient was never supposed to receive OT services. 5. Patient #26 had a start of care date of 10/1/2020 and transferred from agency services on 10/16/2020. Review of the clinical record revealed the following: a. The patient's paper clinical record included a copy of discharge wound care instructions from a wound clinic, dated 9/23/2020, which included the following wound care orders for all three wounds: apply Mupirocin 2 percent and Mepitel/Adaptic non adherent to wound bed, cover with ABD (abdominal wound pad) and rolled gauze, 50-50 mix of Mupirocin and Mometasone to both legs daily, apply Tubigrip daily. b. The POC, dated 10/1/2020 to 11/29/2020, included orders for the skilled nursing services and for the nurse to perform wound care and to cleanse/irrigate the wound using aseptic technique. The POC included orders to apply Mometasone 0.1 percent topical cream 1 application, apply 1 even parts with Mupirocin to bilateral legs and Mupirocin 2 percent topical cream 1 application, apply 1 even parts with Mupirocin to bilateral legs. c. The comprehensive assessment completed at the start of care, dated 10/1/2020, included an assessment of 3 wounds, 1 left calf wound, 1 right leg calf wound and 1 right anterior diabetic ulcer. The nurse documented she cleaned the wounds and applied ointment per physician orders and redressed the wounds. d. The skilled nursing visit notes, dated 10/5 and 10/12/2020, included documentation the nurse provided wound care per the wound clinic orders. The patient's POC lacked complete wound care orders. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of the patient clinical record review, agency complaint log, agency policy review, patient, family, patient representative and staff interview, the agency failed to ensure agency staff coordinated the delivery of care in a way to meet patient individualized needs for 20 of 24 sampled patients (Patients #1, #2, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #23, #24 and #25) receiving home health aide services. The agency reported a current census of 150 patients at the time of the survey including 98 receiving home health aide services. Failure to ensure agency staff effectively coordinated the delivery of care resulted in the patients not receiving care to meet individualized patient needs. Findings include: Review of the agency's undated policy, titled Plan of Care (POC), revealed a registered nurse (RN) is responsible for coordinating the POC when multiple disciplines are involved. Review of the agency's undated policy, titled Implementing Care and Treatment, identified the RN will oversee the assignment of the home health aide in particular. Agency staff will notify the patient and/or caregiver prior to the scheduled visit if there is a change in the schedule of care. Review of the agency's undated policy, titled Client Bill of Rights, identified the patient has the right to participate in, be informed about, and consent to or refuse care in advance of and during treatment with respect to care to be furnished based on comprehensive assessments, establishing and revising the Plan of Care, the disciplines that will furnish services, the frequency of visits, and any changes in care to be furnished. Review of the agency's undated policy, titled Missed Visit Policy, identified if the schedule is altered, agency staff shall provide information on alterations to the patient as soon as possible. In the event of an employee emergency or termination of employment, the agency will provide alternate, qualified staff to complete the required visits. If there is a missed visit, agency staff shall provide services as agreed upon by the patient and agency. Agency staff will coordinate with the patient or patient's authorized representative to reschedule a missed visit whenever possible. Review of the agency's complaint log on 2/8/2020 revealed the following: Patient #1 complained on 10/19/2020 and 12/22/2020 that Staff I, former Home Health Aide, was not showing up for visits. The complaint log lacked any documentation of investigation into the patient's complaints. The complaint log lacked documentation of complaints made by any other patients since 5/18/2020. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: The Plans of Care (POCs), dated 9/1/2020 to 10/30/2020 and 10/31/2020 to 12/29/2020, identified diagnoses of chronic obstructive pulmonary disease, diabetes, multiple sclerosis and heart failure. The POCs included physician orders for skilled nursing services 2 times per week and home health aide services 3 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. The home health aide care plans, dated 9/1 and 10/31/2020, included registered nurse (RN) instructions to the home health aide to complete the following tasks: provide bed bath, assist with dressing, apply lotion to the skin, comb hair, oral care, clean/file nails, incontinence care, record last bowel movement, encourage fluids, turn and reposition and remind the patient to take medications every visit and then shampoo hair weekly. The update to the comprehensive assessment completed at the time of recertification, dated 10/29/2020, identified the patient had difficulty breathing with minimal exertion, was incontinent of bowel and bladder, limited range of motion in the lower extremities, was totally dependent on someone to assist with dressing and bathing and was bedfast. a. The clinical record included documentation of missed home health aide visits notes completed by Staff I, Home Health Aide, dated 10/9, 10/12, 10/15, 10/23, 10/26, 10/30, 11/4, 11/6, 11/11, 11/13, 12/16 and 12/18/2020, for reasons of either no one answering the phone, door or the patient/family being uncooperative. 1) The home health aide visit notes, dated 10/16, 10/19, 10/21, 11/2, 11/9, 11/16, 11/18, 11/20, 11/23, 11/25, 11/27, 11/30, 12/2, 12/4, 12/7, 12/9, 12/11 and 12/14/2020, included documentation by Staff I, Home Health Aide, that she provided personal cares to the patient. Each of the visit notes lacked documentation of completion of all the assigned tasks (See G0800). 2) The Home Health Aide Supervisory Visit notes, dated 10/26, 11/9, 11/23, 12/7 and 12/21/2020, included a signature of completion by Staff C, Licensed Practical Nurse (LPN), and all identified the home health aide was not arriving for visits as scheduled. In addition, the notes, dated 11/23, 12/7 and 12/21, identified the home health aide was not providing care according to the care plan, not performing tasks competently and not honoring the patient's rights. 3) See G478 interview on 2/8/21 at 9:10 AM with the Administrative Assistant. 4) On 2/8/21 at 12:05 PM, during an interview, the Administrator/Clinical Manager explained the Administrative Assistant reported to her about the missed home health aide visits for Patient#1 by Staff I, Home health aide. 5) On 2/8/21 at 3:49 PM, during an interview, Staff I, Home Health Aide, explained the Administrative Assistant called her into the office on 12/22/2020 and told her Patient #1 complained about her not coming to provide home health aide services. She denied falsifying documentation and reported every time she documented she was at the patient's home, she was there. She explained Patient #1 was bed ridden and could not answer the door unless the live-in family member was present. She reported she let people know at the office when she missed a visit due to no one answering the door. She did not notify the nurse. Staff I explained she was told to notify the Administrative Assistant of missed visits and the nurse only if there was a medical issue. She reported her proof that she did the visits was in the visit note, because the patient had to sign the visit note at the end of the visit. She confirmed Patient #1 was cognitively able to say whether or not the home health came to the home and provided cares. 6) See G478 interview on 2/9/21 at 11:38 AM, with patient #1. 7) See G478 interview on 2/9/21 at 1:27 PM with Staff C, LPN. 8) See G486 interview on 2/16/21 at 12:32 PM with Staff D, RN. 9)See G486 interview on 2/16/21 at 2:25 PM with Staff C, LPN. b. The clinical record included documentation of 3 missed home health aide visits the week of 12/20/2020, dated 12/21, 12/23 and 12/25/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. 1) On 2/9/21 at 11:38 AM, during an interview, the patient reported the patient did not refuse any services the week of 12/20/2020. The patient reported the agency did not call or offer any services that week. 2) See G434 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. 3) See G434 interview on 2/16/21 at 3:20 PM with Administrator/Clinical Manager. 4) See G434 interview on 2/17/21 at 8:34 AM, with Administrative Assistant. Agency staff failed to investigate and resolve the patient's complaints regarding lack of care, prevent further violations, and notify the patient of an inability to meet personal care needs during the week of 12/20/2020 resulting in an overall lack in coordination of care delivery. 2. Patient #2 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: The POC, dated 10/30/2020 to 12/28/2020 and 12/29 to 2/26/2020, identified diagnoses of hypertension, diabetes, orthostatic hypotension (drop in blood pressure with position change, usually lying or sitting to standing and can cause dizziness or lightheadedness) and Parkinson's Disease and included orders for skilled nursing services 1 time per week and home health aide services 2 times per week. The update to the comprehensive assessment completed at the time of recertification, dated 12/25/2020, identified the patient was a fall risk, had difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, oriented to person and place, required prompting if in stressful or new situations, required set-up assistance for grooming, toilet hygiene and dressing, but required assistance or supervision to bathe. The home health aide care plans, dated 9/3, 10/28 and 12/25/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, encourage fluids and remind the patient to take medications. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/26 through 12/21/2020. a. The home health aide visit notes, dated 10/26, 10/30, 11/3, 11/6, 11/10, 11/12, 11/16, 11/19, 11/23, 11/26, 11/30, 12/5, 12/8, 12/10, 12/14, 12/17 and 12/21/2020, included documentation the home health aide encouraged the patient drink fluids and reminded the patient to take medications. The home health aide failed to document if she completed the tasks of showering with a chair and assisting the patient with dressing, or a reason why the home health aide failed to complete the assigned tasks. 1) The Home Health Aide Supervisory visit notes, dated 11/4, 11/19, 12/3 and 12/17/2020, included documentation by Staff E, RN, which identified the home health was following the aide care plan and completing the assigned tasks. 2) On 2/9/21 at 9:25 AM, during an interview, the patient reported Staff I, Home Health Aide, told the patient she did not have time to help the patient with a shower. The patient reported he/she needed help with a shower and did not get the help and services the he/she needed. The patient reported he/she did not tell anybody about not getting help with showering. 3) On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, explained she interviews the patient when supervising the home health aide. She will ask the patient about communication, if the home health aide is providing services as scheduled and following the care plan. She denied Patient #2 ever complained about home health aide services provided by Staff I, Home Health Aide. She does not review home health aide documentation when supervising the home health aide. b. The clinical record included documentation of 2 missed home health aide visits the week of 12/27/2020, dated 12/28 and 12/31, and 2 missed home health visits the week of 1/3/21, dated 1/4 and 1/7/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. 1) See G434 interview on 2/9/21 at 9:25 AM with patient #2. 2) See G434 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. 3) The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/27/2020 and 1/3/21. Agency staff failed to ensure the coordination of the delivery of home health aides services to meet the needs of the patient. 3. Patient #4 had a start of care date of 9/21/2020. Review of the clinical record revealed the following: a. The POC, dated 11/20/2020 to 1/18/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The home health aide care plan, dated 11/16/2020, included RN instructions to the home health aide to complete the following tasks: tub bath, assist with dressing, encourage fluids, and remind the patient to take medications. c. The update to the comprehensive assessment completed at the time of recertification, dated 11/17/2020, identified the patient did not have a capable caregiver, the patient was blind, a fall risk, had difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, poor balance, required set up assistance for grooming and dressing and intermittent assistance with bathing (for supervision, encouragement, reminders, getting in and out of the shower and/or washing difficult to reach areas). d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 11/17 to 12/22/2020. e. The clinical record included documentation of 1 missed home health aide visit the week of 12/20/2020, dated 12/24, and one missed home health aide visit the week of 12/27/2020, dated 12/31. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. On 2/9/21 at 10:03 AM, during an interview, the patient reported he/she did not refuse home health aide visits the weeks of Christmas and New Years. The patient reported staff were supposed come and no one showed. The patient reported calling the office, because of no one showing up and was told about Staff I, Home Health Aide, at that time. Agency staff failed to ensure the delivery of the coordination of care in regards to home health aide services for the patient. 4. Patient #5 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: The POC, dated 11/9/2020 to 1/7/2021, included physician orders for skilled nursing and home health aide services 1 time per week. The home health aide care plan, dated 11/16/2020, included RN instructions to the home health aide to remind the patient to take medications. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient was a fall risk, had dyspnea with moderate exertion, activity intolerance, incontinent of urine, oriented to person only, requires prompting under stressful or unfamiliar conditions, confused during day and evening but not constantly, poor balance, weakness, shuffling gait, required set up assistance for grooming, dressing and toilet hygiene and intermittent assistance with showering. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits 1 time per week, dated 11/13, 11/20, 11/27, 12/4, 12/12 and 12/18/2020. a. The clinical record included documentation of 1 missed home health aide visit the week of 12/20/2020, dated 12/25. The missed visit note included the following reason: cancellation of care by Staff J, Home Health Aide. 1) See G478 interview on 2/9/21 at 10:56 AM patient #5. 2) The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/20/2020. b. See G478 interview on 2/9/21 at 10:56 AM with patient #5. 1) See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. 2) See G478 interview on 2/16/21 at 3:00 PM with the Administrative Assistant. Agency staff failed to document, investigate and resolve the patient's complaint regarding lack of care, prevent further violations, and notify the patient of an inability to meet personal care needs during the week of 12/20/2020 resulting in an overall lack in coordination of care delivery. 5. Patient #7 had a start of care date of 9/28/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/28/2020 to 11/26/2020 and 11/27/2020 to 1/25/2020, included orders for skilled nursing and home health aide services. b. The comprehensive assessment completed at the start of care, dated 9/28/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 11/23/2020, identified the patient was a fall risk, had a lack of caregiver/family support, a fall risk, incontinent of urine, poor balance, muscle weakness, difficulty breathing with moderate exertion, required set up assistance with grooming and intermittent assistance with bathing. c. The home health aide care plans, dated 9/30, 11/23 and 11/27/2020, included RN instructions to the home health aide to complete the following tasks: shower, assist with dressing, apply lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfers, remind the patient to take medications every visit, and then clean/file nails and shave weekly. d. The home health aide visit notes, dated 10/8, 10/15, 10/21, 10/22, 10/27, 10/30, 11/3, 11/6, 11/10, 11/17, 11/20, 11/24, 11/28, 12/1, 12/5, 12/8, 12/11, 12/15 and 12/17/2020, included documentation Staff I, Home Health Aide, went to the patient's home to provide a service. Each visit lacked documentation Staff I, Home Health Aide, provided services and completed tasks according to the home health aide care plan (See G0800). e. The Home Health Aide Supervisory visit notes, dated 10/13, 10/26 and 11/19/2020, included documentation Staff G, RN, supervised Staff L, Home Health Aide, and determined the home health aide had followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. The clinical record lacked documentation Staff L had provided any home health aide services in the home. f. The Home Health Aide Supervisory visit note, dated 11/24/2020, included documentation Staff C, LPN, had supervised a home health aide (did not designate a specific home health aide) and determined the home health aide followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. g. The Home Health Aide Supervisory visit notes, dated 12/1 and 12/15/2020, included documentation Staff C, LPN, supervised Staff M, Home Health Aide, and determined the home health aide had followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. The clinical record lacked documentation Staff M had provided any home health aide services in the home. On 2/16/21 at 12:03 PM, during an interview, Staff G, RN, reported she supervises home health aides at either a visit or update to the comprehensive assessment at recertification by asking the patient how the home health aide is doing and if there are any concerns. She reported sometimes the home health aide is present. She reported she occasionally reviews home health aide documentation, but this is usually the Administrator/Clinical Manager's job. She denied the patient every complained of issues with cares. Agency staff failed to coordinate care and ensure the patient received home health aide services as ordered to meet the needs of the patient. 6. Patient #8 had a start of care date of 8/27/2020. Review of the clinical record revealed the following: a. The POC, dated 8/27/2020 to 10/25/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week. b. The POC, dated 10/26/2020 to 12/24/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week for 5 weeks, 1 time per week for 1 week, and no home health aide services the last 3 weeks of the certification period. c. The comprehensive assessment completed at the start of care, dated 8/27/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 10/21/2020, identified the patient did not have a capable caregiver, was a fall risk, had difficulty breathing with minimal exertion, used 4 liters of oxygen per minute per nasal cannula, required prompts or became confused if new or stressful situations, forgetful, muscle weakness, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. d. The home health aide care plans, dated 8/28 and 10/23/2020, included RN instructions to the home health aide to complete the following tasks: shower, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. e. The clinical record included documentation of completed and missed home health aide visits by Staff I, former Home Health Aide, dated 10/14 to 11/30/2020. The home health aide visits, dated 10/14, 10/19, 10/21, 11/2, 11/9, 11/11, 11/16, 11/18, 11/23, 11/25 and 11/30/2020 , included documentation by Staff I, Home Health Aide, that she provided personal cares to the patient. Each of the visit notes lacked documentation of completion of all the assigned tasks (See G0800). f. The clinical record included documentation of missed visits, dated 10/16 (due to only seeing patient on Mondays), 10/26, 10/28 and 11/4/2020. See G478 interview on 2/9/21 at 1:40 PM with patient #8. g. An interim physician order, dated 12/2/2020, included orders to discontinue home health aide services per the patient's request. See G486 interview on 2/16/21 at 12:32 PM with Staff D, RN. h. The Home Health Aide Supervisory visit notes, dated 10/28, 11/11, 11/25 and 12/2/2020, included documentation Staff D, RN, completed the note and documented the home health aide followed the patient's care plan, arrived for visits as scheduled, maintains open communication with the patient and honored the patient's rights. Agency staff failed to document, investigate and resolve the patient's complaints regarding lack of care and prevent further violations resulting in an overall lack in coordination of care delivery. 7. Patient #9 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. A patient signed consent form for care and services, signed by the patient and agency staff on 11/9/2020, identified the agency planned to provide skilled nursing, home health aide and physical therapy services. b. The POC, dated 11/9/2020 to 1/7/2021, identified a diagnosis of fracture of the first lumbar vertebra and included orders for skilled nursing 1 time per week, home health aide services 2 times per week and physical therapy services 1 time the first week and then 2 times for 3 weeks. c. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient suffered from lower back pain with an intensity of 3 to 10 (with 10 the worst) all the time, occasional incontinence, at risk for falls, oriented to person and place, forgetful, but lacked a memory deficit, confused in new or complex situations, required assistance with set up for grooming and upper body dressing, dependent on assistance for lower body dressing, unable to shower without assistance, unable to maintain toilet hygiene and transfer without assistance and chairfast, but able to wheel self independently. d. The home health aide care plan, dated 11/10/2020, included RN instructions to the home health aide to complete the following tasks: chair bath, tub bath, shower with chair, assist with dressing, lotion, shampoo hair, assist to toilet and incontinence care. e. The home health aide visit notes, dated 11/19, 11/23, 11/25, 11/30, 12/3, 12/7, 12/10 (documented on two different days and 2 different notes for the same day) and 12/16/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks or a reason why the aide failed to complete the assigned tasks. See G434 interview on 2/10/21 at 2:09 PM with patient# 9. See G434 interview on 2/16/21 at 12:17 PM with Staff H, RN. Agency staff failed to honor patient rights and provide coordination of care and services provided to the patient. 8. Patient #10 had a start of care date of 7/21/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/19/2020 to 11/17/2020 and 11/18/2020 to 1/16/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The home health aide care plans, dated 9/19 and 11/18/2020, included RN instruction to the home health aide to complete the following tasks: chair bath, assist with dressing, lotion, comb hair, shampoo, oral care, clean dentures, assist to bedside commode, incontinence care, record last bowel movement, meal set up, assist with ambulation, assist with transfers and remind the patient to take medications every visit and clean/file nails and shave weekly. c. The update to the comprehensive assessments completed at the time of recertification, dated 9/17 and 11/17/2020, identified the patient had chronic respiratory failure, the patient's caregiver suffered from burnout incontinence of urine, activity intolerance, suffered from dizziness, oriented to person and place but forgetful, required set up assistance with dressing and toilet hygiene and required assistance for bathing. d. The clinical record included documentation Staff N, Home Health Aide provided home health aide visits, dated 10/6, 11/3, 11/5, 11/10, 11/12, 12/1, 12/3, 12/8, 12/10, 12/15 and 12/17/2020. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9, 11/17, 11/19, 11/24 and 11/27/2020. Each of the visit notes lacked documentation of completion of all the assigned tasks (See G0800). f. The clinical record included documentation Staff L, Home Health Aide, provided home health aide visits, dated 10/13, 10/16, 10/20 and 10/22/2020. g. The clinical record included documentation Staff J, Home Health Aide, provided home health aide visits, dated 12/23 and 12/31/2020. h. A home health aide missed visit note, dated 12/24/2020, included documentation Staff J, Home Health Aide completed the form and documented the reason as "cancellation of care". i. A home health aide missed visit note, dated 12/29/2020, included documentation Staff J, Home Health Aide completed the form and documented the reason as "family/caregiver able to assist". j. The clinical record included documentation of 2 missed home health aide visits the week of 1/3/21, dated 1/5 and 1/7/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. k. The Home Health Aide Supervisory visit notes, dated 10/19, 11/2, 11/16, 11/19, 12/3, 12/17, 12/31, included documentation Staff C, LPN, supervised only Staff N, Home Health Aide. See G434 interview on 2/10/21 at 9:02 AM with patient #10. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the weeks of 12/20 and 12/27/2020 and 1/3/21. Agency staff failed to ensure the patient received home health aide services according to the care plan and notify the patient of the agency's inability to provide home health aide services as scheduled resulting in an overall lack of coordination of care. 9. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: The POC, dated 10/9/2020 to 12/7/2020, included orders for home health aide services 2 times per week and skilled nursing services weekly. The POC, dated 12/8/2020 to 2/5/2021, included orders for skilled nursing and home health aide services 1 time per week. The update to the comprehensive assessment completed at the time of recertification, dated 10/5/2020, identified the following: a primary diagnosis of Parkinson's Disease, absence of a capable caregiver, fall risk, difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, oriented to person and place, forgetful, poor balance, muscle weakness, unsteady gait, required set up assistance with dressing, grooming and toilet hygiene and needed intermittent assistance with showering. The home health aide care plans, dated 10/6 and 12/8/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. a. The home health aide visit notes, dated 10/20, 11/6, 11/10, 11/13, 11/17, 11/24, 12/9 and 12/18/2020, included documentation by Staff I, Home Health Aide, that she provided home health aide services to the patient. Each of the visit notes lacked documentation of completion of all the assigned tasks (See G0800). The Home Health Aide Supervisory visit notes, dated 11/9, 11/23, 12/7 and 12/21/2020, included documentation Staff E, RN, supervised Staff I, Home Health Aide, and documented the home health aide followed the care plan to complete tasks. b. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9 to 12/18/2020. The clinical record included documentation by Staff J, Home Health Aide, of a missed home health aide visit the week of 12/20/2020, dated 12/25, due to a visit cancellation, and a missed home health aide visit the week of 12/27/2020, dated 1/1/21, due to a "hurt back". See G434 interview on 2/10/21 at 11:30 AM with patient #11. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant described the patient as forgetful, and reported the patient did call the office about not getting services, but not until after the termination of Staff I, Home Health Aide. Agency staff failed to ensure the patient received home health aide services according to the care plan, notify the patient of the agency's inability to provide home health aide services as scheduled, document the existence, investigation and resolution of a complaint related to lack of services resulting in an overall lack of coordination of care. 10. Patient #12 had a start of care date of 11/18/2020. Review of the clinical record revealed the following: a. The POC, dated 11/18/2020 to 1/16/2020, included orders for skilled nursing services 1 time per week and home health aide services 3 times per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care, dated 11/18/2020, identified the patient did not have a capable caregiver, was a fall risk, oriented times three (person, place and time), but forgetful, required set up assistance for dressing, grooming and toilet hygiene and required intermittent assistance with bathing. c. The home health aide care plan, dated 11/23/2020, included RN instructions to the home health aide to complete the task of reminding the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 12/7 to 12/18/2020. See G478 interview on 2/11/21 at 8:58 AM with patient #12. See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. Agency staff failed to document the existence, investigation and resolution of a complaint related to home health aide possible not providing services resulting in lack of coordination of care. 11. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: The POC, dated 8/31/2020 to 10/29/2020, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. An interim physician order, dated 9/21/2020, included an order to increase home health aide services to 3 times per week. The POCs, dated 10/30/2020 to 12/28/2020 and 12/29/2020 to 2/26/2021, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. The update to the comprehensive assessment completed at the time of recertification, dated 12/28/2020, identified the patient had a diagnosis of chronic obstructive pulmonary disease, was a fall risk, caregiver burnout, oriented to person and place, forgetful, difficulty breathing with minimal exertion, activity intolerance, urinary incontinence, poor balance, muscle weakness, required set up assistance with grooming and dressing and intermittent assistance with bathing. The home health aide care plans, dated 9/8 and 10/29/2020, included RN instructions to the home health aide to complete the following tasks: tub bath, assist with dressing, lotion and remind the patient to take medications. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9 to 11/27/2020, and then documented missed home health aide visits, dated 11/30, 12/2, 12/4, 12/7 and 12/9/2020. a. The clinical record included documentation Staff J, Home Health Aide, provided home health aide visits, dated 12/11 to 12/21/2020, and then documented missed visits, dated 12/23 and 12/25/2020 (cancellation of care), 12/28 and 12/30/2020 (doctor appointment) and 1/1/21 (black ice, staff couldn't leave house). The patient received one home health aide visit the week of 12/20 and no home health aide visits the week of 12/27/2020. See G434 interview on 2/10/21 at 12:48 PM with patient #13. b. The home health aide visit notes, dated 10/9, 10/12, 10/14, 10/19, 10/21, 10/23, 10/26, 10/30 and 11/16/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks (tub bath, assist with dressing, lotion and remind the patient to take medications), or a reason why the home health aide failed to complete the assigned tasks. 1) The home health aide visit notes, dated 10/16, 10/28, 11/2, 11/4, 11/9, 11/11,11/23, 11/25 and 11/27/2020, included documentation the home health aide completed the task of reminding the patient to take medication, but lacked documentation the home health aide completed the other assigned tasks, or a reason why the home health aide failed to complete the rest of the assigned tasks. 2) The Home Health Aide Supervisory visit notes, dated 10/30, 11/13, 11/27 and 12/11/2020, included documentation Staff C, LPN, had supervised the home health aide and documented the home health aide followed the care plan, arrived for visits as scheduled, demonstrated competency and honored patient rights. See G478 interview on 2/10/21 at 12:48 PM with patient #13. See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. The complaint log and clinical record lacked any documentation of an existence or investigation of the patient's complaint of not receiving care and services to meet the needs of the patient. c. The week of 10/4/2020, included documentation of a home health visit, dated 10/5, a missed home health aide visit with physician notification on 10/7, and a missed home home health aide visit with no physician notification, dated 10/9. The week of 10/11/2020, included documentation of 2 missed home health aide visits with no physician notification, dated 10/12 and 10/14. The week of 10/18/2020 included documentation of 3 missed home health aide visits with no physician notification, dated 10/19, 10/21 and 10/23. The week of 10/25, included documentation of 2 missed home health aide visits with no physician notification, dated 10/26 and 10/30. 1) The week of 11/22/2020, included documentation of 3 home health aide visits, dated 11/23, 11/25 and 11/27. The POC included orders for only 2 home health aide visits per week. The clinical record lacked documentation of an order for an extra home health aide visit the week of 11/22. 2) The week of 12/13/2020, included documentation of 3 home health aide visits, dated 12/14, 12/16 and 12/18. The POC included orders for only 2 home health aide visits per week. The clinical record lacked documentation of an order for an extra home health aide visit the week of 12/13. On 2/22/21 at 3:30 PM, during an interview, the Administrative Assistant reported she checked the computer and hard copy of the medical chart and confirmed the home health aide provided an extra home health aide visit without an order the weeks of 11/22 and 12/13/2020. Agency staff failed to investigate and resolve the patient's complaint regarding lack of care, notify the patient of an inability to meet personal care needs during the weeks of 12/20 and 12/27/2020 and ensure home health aide staff provided visits and services according to the POC resulting in an overall lack in coordination of care delivery. 12. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: The POCs, dated 8/24/2020 to 10/22/2020, 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. The updates to the comprehensive assessment completed at the time of recertification, dated 10/20 and 12/21/2020, identified the patient was at risk for falls, activity intolerance, poor balance, muscle weakness, unsteady gait, difficulty breathing with moderate exertion, bladder incontinence, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. The home health aide care plan, dated 8/24, 10/21 and 12/21/2020, included RN instructions to the home health aide to complete the following task: record the patient's last bowel movement. The clinical record included documentation Staff J, Home Health Aide, provided home health aide visits, dated 12/14 to 12/28/2020. a. The week of 12/20/2020 included of 1 home health aide visit, dated 12/21, and one missed home health aide visit, dated 12/25 (reason- missed, other), completed by Staff J, Home Health Aide. On 2/10/21 at 3:15 PM, during an interview, the patient reported the patient was not notified the agency staff would not be providing services for as scheduled during the week of 12/20/2020. b. The Home Health Aide Supervisory visit note, dated 10/30/2020, completed by Staff Q, LPN, included documentation she had supervised the home health aide and documented the home health aide was not maintaining open communication, not arriving for visits as scheduled, not following the care plan and not demonstrating competency in completing tasks. Staff Q documented this as an issue with how the patient wanted the house cleaned. 1) The Home Health Aide Supervisory visit notes, dated 11/10, 12/8 and 12/21/2020, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication, arrived for visits as scheduled, followed the care plan and completed tasks competently. 2) See G478 interview on 2/10/21 at 3:15 PM with patient #14. 3) See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. 4) See G478 interview on 2/16/21 at 3:00 PM with Administrative Assistant. c. The home health aide visits, dated 10/9, 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23, 12/11, 12/14 and 12/21/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed the assigned personal care task. All of these visits were missed home health aide visits since the home health aides failed to provide any personal care. 1) The home health aide visits the weeks of 10/4, 10/25, 11/22, 12/13 and 12/20/2020, included documentation of one missed home health aide visit with physician notification and 1 missed home health aide visit without physician notification, dated 10/9, 10/26, 11/23, 12/14 and 12/21/2020. 2) The home health aide visits the weeks of 10/11, 10/18, 11/1, 11/8 and 11/15/2020, included documentation of 2 missed home health aide visits with no physician notification, dated 10/12, 10/16, 10/19, 10/23, 11/2, 11/6, 11/9, 11/13, 11/16 and 11/20/2020. 3) The home health aide visits the week of 12/6/2020, included documentation of signed visit, dated 12/7, but the visit note lacked documentation of the completion of any tasks. A second visit note for the week, dated 12/11, included documentation of the completion of only homemaker tasks. The clinical record lacked documentation of physician notification of the 2 missed home health aide visits for the week of 12/6. d. The home health aide visits, dated 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23 and 12/11/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed the assigned personal care task, or a reason why the home health aide failed to complete the assigned task. The home health aide visit, dated 12/7/2020, included documentation of a signature of completion, but lacked documentation of the completion of any tasks, or a reason why the home health aide failed to do any tasks. Agency staff failed to ensure the patient received home health aide services according to the care plan, notify the patient of the agency's inability to provide home health aide services as scheduled, document the existence, investigation and resolution of a complaint related to lack of services resulting in an overall lack of coordination of care. 13. Patient #15 had a start of care date of 9/17/2020. Review of the clinical record revealed the following: The POCs, dated 9/17/2020 to 11/15/2020 and 11/16/2020 to 1/14/2021, included physician orders for skilled nursing and home health aide services 2 times per week. The comprehensive assessment completed at the start of care, dated 9/17/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 11/12/2020, identified the patient had chronic obstructive pulmonary disease, diabetes, was a fall risk, had difficulty breathing, used 3 liters of oxygen per minute, activity intolerance, poor balance, absence of a capable caregiver, incontinent of urine, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and required intermittent assistance with bathing. The home health aide care plans, dated 9/17, 11/3 and 11/16/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. 1) The clinical record included documentation the Administrator/Clinical Manager completed 2 missed home health aide visit notes the week of 12/20/2020, dated 12/22 and 12/25, due to the patient being uncooperative, and 2 missed home health aide visit notes the week of 12/27/2020, dated 12/29/2020 (no reason given) and 1/1/21. The Administrator/Clinical Manager documented the patient was uncooperative for a visit on 1/1/21. 2) On 2/10/21 at 3:45 PM, during an interview, the patient reported the patient did not refuse home health aide services the weeks of Christmas (12/20/2020) and New Year's (12/27/2020), and the patient did not know why the patient did not get services those weeks. 3) The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the weeks of 12/20 and 12/27/2020. b. The home health aide visit notes, dated 10/6, 10/9, 10/14, 10/16, 10/20, 10/27, 11/3, 11/6, 11/10, 11/13, 11/17, 11/20, 11/24, 11/27, 12/1, 12/4, 12/8, 12/11, 12/15 and 12/18/2020, lacked documentation or a reason why the home health aide failed to complete assigned tasks per the home health aide care plan (see G0800). 1) The Home Health Aide Supervisory visit notes, dated 10/13 and 10/27/2020, completed by Staff Q, LPN, included documentation she had supervised the home health aide and documented the home health aide followed the care plan. 2) The Home Health Aide Supervisory visit notes, dated 11/10, 11/24, 12/8 and 12/22/2020, included documentation Staff E, RN, supervised the home health aide and documented the home health aide followed the care plan. Agency staff failed to ensure the patient received home health aide services according to the care plan and notify the patient of the agency's inability to provide home health aide services as scheduled resulting in an overall lack of coordination of the delivery of care. 14. Patient #16 had a start of care date of 2/10/2020. Review of the clinical record revealed the following: The POC, dated 12/2/2020 to 1/30/2021, included physician orders for skilled nursing and home health aide services 2 times per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. The update to the comprehensive assessment, dated 10/1/2020, identified the patient had alcoholic cirrhosis of the liver, muscle weakness and chronic obstructive pulmonary disease, was a fall risk, lack of caregiver/family support, difficulty breathing with minimal exertion, activity intolerance, incontinent of urine, oriented to person and place, forgetful, required assistance with grooming and bathing and set up assistance with dressing. The home health aide care plan, dated 12/1/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. 1) See G478 interview on 2/11/21 at 10:21 AM with patient #16. 2) See G478 interview on 2/16/21 at 3:00 PM with Administrative Assistant. 3) The complaint log and clinical record lacked any documentation of an existence, investigation or resolution of the patient's complaint of not receiving care and services to meet the needs of the patient. b. The home health aide visit notes, dated 12/1, 12/4, 12/7, 12/9, 12/14, 12/16 and 12/21/2020, lacked documentation or a reason why the home health aide failed to complete assigned tasks per the home health aide care plan (see G0800). The Home Health Aide Supervisory visit note, dated 12/15/2020, completed by Staff C, LPN, documented she supervised Staff I, Home Health Aide, and that Staff I maintained open communication with the patient, arrived for visits as scheduled, followed the care plan and demonstrated competency with tasks performed. c. The POC, dated 10/3/2020 to 12/1/2020, included a physician order for skilled nursing services 2 times the first week and then 1 time a week for 8 weeks. The week of 10/11/2020 included documentation of 2 skilled nursing visits, dated 10/13 and 10/15. The clinical record lacked documentation of a physician order for the extra skilled nursing visit. Agency staff failed to ensure staff followed the Plan of Care for the delivery of services, ensure home health aide staff followed the home health aide care plan and document the existence, investigate and resolve the patient's complaint of not receiving home health aide services to meet the needs of the patient which resulted in an overall lack of coordination of the delivery of care. 15. Patient #17 had a start of care date of 11/30/2020 and transferred from agency services on 1/14/21. Review of the clinical record revealed the following: The POC, dated 11/30/2020 to 1/28/2021, included orders for skilled nursing services 2 times the first week and then 1 time per week for 8 weeks and an order for home health aide services 2 times per week. The comprehensive assessment completed at the start of care, dated 11/30/2020, identified the patient had heart failure and respiratory failure, absence of a capable caregiver, difficulty breathing with minimal exertion, incontinent of urine, oriented to person and place, forgetful, a fall risk, poor balance, muscle weakness, required set up assistance with upper body dressing and grooming, assistance with lower body dressing and intermittent assistance with bathing. The home health aide care plan, dated 11/30/2020, included RN instructions to the home health aide to complete the following tasks: provide bed bath, assist with dressing, apply lotion to the skin, comb hair, clean/file nails, incontinence care, record last bowel movement, encourage fluids, assist with ambulation and remind the patient to take medications. 1) The week of 12/20/2020 included of 1 home health aide visit, dated 12/23, and one missed home health aide visit, dated 12/25 (reason- canceled), completed by Staff J, Home Health Aide. The week of 12/27/2020 included documentation of 1 home health aide visit, dated 12/30, and one missed home health aide visit, dated 1/1/21 (reason-canceled). 2) The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the weeks of 12/20 and 12/27/2020. b. The home health aide visit notes, dated 12/2, 12/7 and 12/101/2020, lacked documentation or a reason why the home health aide failed to complete assigned tasks per the home health aide care plan (see G0800). The Home Health Aide Supervisory visit note, dated 12/9/2020, included documentation Staff E, RN, supervised the home health aide, and documented the home health aide followed the care plan. Agency staff failed to ensure the patient received home health aide services according to the care plan and notify the patient of the agency's inability to provide home health aide services as scheduled resulting in an overall lack of coordination of the delivery of care. 16. Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: The POCs, dated 8/17/2020 to 10/15/2020, 10/16/2020 to 12/14/2020 and 12/15/2020 to 2/12/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. The update to the comprehensive assessment completed at the time of recertification, dated 12/14/2020, identified the patient had chronic kidney failure, atrial fibrillation, did not have a capable caregiver, was short of breath with moderate exertion, had fatigue and weakness, incontinent of urine, at risk for falls, poor balance, unsteady gait, oriented to person and place, forgetful, required set up assistance with grooming and dressing and intermittent assistance with bathing. The home health aide care plans, dated 8/17, 10/14 and 12/14/2020, included RN instructions to the home health aide to complete the following personal care tasks: limit fluids and remind the patient to take medications. 1) The week of 12/20/2020 included of 2 missed home health aide visits, dated 12/23 and 12/25 (reason- canceled), completed by Staff J, Home Health Aide. The week of 12/27/2020 included documentation of 1 home health aide visit, dated 12/30, and one missed home health aide visit, dated 1/1/21 (reason-"complications with my back"). 2) The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the weeks of 12/20 and 12/27/2020. b. The home health aide visit note, dated 10/9/2020, included documentation the home health aide completed homemaker tasks, but none of the assigned personal care tasks, or a reason why the home health aide failed to complete the assigned tasks. 1) The home health aide visit note, dated 10/14, 10/20, 10/28, 10/30, 11/4, 11/6, 11/10, 11/13, 11/17, 11/20, 11/25, 11/27, 12/1, 12/4, 12/8, 12/11, 12/16 and 12/18/2020, included documentation the home health aide completed the tasks of reminding the patient to take medications, but failed to include documentation of a reason why the home health aide failed to complete the assigned task of limiting fluids. 2) The Home Health Aide Supervisory visit notes, dated 10/20 and 11/3/2020, included documentation Staff C, LPN, supervised the home health aide, and documented the home health aide followed the care plan. 3) The Home Health Aide Supervisory visit notes, dated 11/17 and 12/1/2020, included documentation Staff E, RN, supervised the home health aide, and documented the home health aide followed the care plan. c. The POCs included orders for the skilled nurse to do a complete physical assessment every visit with focus on high blood pressure, assess co-morbidities and other conditions, provide instruction on management of chronic obstructive pulmonary disease and on disease process related to cardiovascular function. 1) The clinical record included documentation of skilled nursing visits, dated 10/5, 10/12, 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 12/11, 12/14, 12/21 and 12/28/2020. The clinical record included documentation of 1 missed skilled nursing visit, dated 11/30/2020. The clinical record lacked documentation of any difficulty agency nursing staff had with completing nursing visits. 2) The update to the comprehensive assessment completed at discharge by the Administrator/Clinical Manager, dated 1/4/21, included documentation the patient's physician and the patient were in agreement to discharge the patient due to the patient's refusal of services. The discharge assessment also documented the agency was discharging the patient due to non-compliance with skilled nursing visits, the patient was able to verbalize who to follow up with post discharge, agency staff notified the patient's physician of the discharge and the discharge would be sent to the physician within 5 days. 3) A physician order, dated 1/4/21 and time of 3:45 PM and effective 1/4/21, including the following order: please discharge patient from the agency due to the patient's non-compliance. The Administrative Assistant (who is not a nurse or clinician) signed the clinician section of the order on 1/21/21. The physician signed the order on 1/25/21. 4) A Discharge Summary included documentation of a signature of completion by the Administrator/Clinical Manager, dated 1/22/21. 5) The clinical record lacked any documentation with the physician or patient prior to the completion of the discharge assessment in regards to the agency planning on discharging the patient for cause related to non-compliance with skilled nursing visits. The clinical record lacked documentation the agency made efforts to resolve the problem with non-compliance and provided the patient with contact numbers for other community resources or providers that may be able to provide services to the patient. 6) On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, reported sometimes the patient would not answer the door and staff would have to go back several times in order to get the visit done. 7) On 2/16/21 at 3:40 PM, during an interview, the Administrative Assistant reported for discharges prior to the end of the certification, the agency's usual process is to send notification to the physician and the physician signs the order and sends the order back. She reported sometimes she calls the physician. She thought there probably was not any documentation to show she had a discussion with the physician in regards to Patient #18 prior to the patient's discharge. 8) On 2/17/21 at 8:34 AM, during an interview, the Administrative Assistant reported an inability to find documentation in the clinical record of contact made the physician prior to discharging the patient. 9) On 2/17/21 at 8:43 AM, during an interview, the Administrator/Clinical Manager reported for discharges prior to the end of the certification, staff will send an order and discharge summary to the patient's physician. The physician will call if the physician disagrees with the discharge. Agency staff failed to ensure the patient received home health aide services according to the POC, failed to ensure home health aides followed the home health aide care plan, failed to show just cause and coordinate associated discharge planning with the patient and the patient's physician resulting in an overall lack of the coordination in the delivery of care. 17. Patient #20 had a start of care date of 10/16/2020 and discharged from agency services on 12/7/2020. Review of the clinical record revealed the following: a. The POC, dated 10/16/2020 to 12/14/2020, identified diagnoses of urinary tract infection and dementia with behavioral disturbance and included physician orders for home health aide services 2 times per week and skilled nursing services 1 time the first week, 2 times per week for 2 weeks and 1 time per week for 6 weeks. b. The comprehensive assessment completed at the start of care, dated 10/16/2020, identified the patient required 24 hour supervision, had difficulty breathing with moderate exertion, activity intolerance, fatigue/weakness, oriented to person and place, forgetful, with increased episodes of severe confusion, impaired decision making, verbally disruptive, at risk for falls, poor balance, unsteady gait, required assistance for grooming, dressing, toilet hygiene and bathing. c. The home health aide care plan, dated 10/16/2020, included RN instructions to the home health aide to complete the following tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, clean dentures, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/20, 10/22, 10/27, 10/29, 11/3, 11/5, 11/9, 11/12, 11/17, 11/19, 11/24, 12/1 and 12/5/2020, lacked documentation or a reason why the home health aide failed to complete assigned tasks per the home health aide care plan (see G0800). e. The Home Health Aide Supervisory visit notes, dated 10/29, 11/12 and 11/26/2020, included documentation Staff C, LPN, supervised the home health aide and documented the home health aide maintained open communication with the patient, family, caregiver, representative, arrived for assigned visits as scheduled, followed the patient's care plan and demonstrated competency with assigned tasks. See G478 interview on 2/11/21 at 11:29 AM with a family member/caregiver. See G478 interview on 2/11/21 at 2:08 PM with the patient's representative/family member. See G478 interview on 2/16/21 at 12:03 PM with Staff G, RN. See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. See G478 interview on 2/16/21 at 3:00 PM with Administrative Assistant. The complaint log and clinical record lacked any documentation of an existence, investigation or resolution of the patient representative's complaint of not receiving care and services to meet the needs of the patient. Agency staff failed to document the existence, investigate or resolve a complaint made by the patient's representative, ensure agency staff maintained open communication with the patient's representative and failed to ensure home health aides provided services according to the care plan resulting in an overall lack of coordination in the delivery of care. 18. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The POC, dated 10/13/2020 to 12/11/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The POC, dated 12/12/2020 to 2/9/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. c. The update to the comprehensive assessment completed at the time of recertification, dated 12/9/2020, identified the patient had diabetes, high blood pressure, heart failure, was a fall risk, absence of a capable caregiver, difficulty breathing with minimal exertion, oriented to person and place, forgetful, poor balance, muscle weakness, required set up assistance for grooming and dressing and intermittent assistance for bathing. d. The home health aide care plans, dated 10/13 and 12/9/2020, included RN instructions to the home health aide to complete the following personal care tasks: remind the patient to take medications. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 10/20 to 12/21/2020. f. The home health aide visit note, dated 10/23/2020, included documentation Staff I, Home Health Aide, completed homemaker tasks, but lacked documentation or a reason why the home health aide failed to complete the assigned personal care task of reminding the patient to take medications. g. The home health aide visit notes, dated 10/20, 10/30, 11/3, 11/6, 11/9, 11/11, 11/13, 11/18, 11/20, 11/23, 11/30, 12/2, 12/7, 12/9, 12/14, 12/18 and 12/21/2020, included documentation Staff I, Home Health Aide, completed the assigned personal task of reminding the patient to take medications. h. The Home Health Aide Supervisory visit notes, dated 11/11, 11/25, 12/9 and 12/23, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication with the patient, arrived for assigned visits as scheduled, followed the care plan and demonstrated competency in assigned tasks. See G478 interview on 2/16/21 at 11:15 AM with patient #23. See G478 interview on 2/16/21 at 12:56 PM with Staff E, RN. . See G478 interview on 2/16/21 at 3:00 PM with Administrative Assistant. Agency staff failed to document the existence, investigation and resolution of multiple complaints made by the patient in regards to not receiving home health aide services resulting in lack of coordination of the delivery of care. 19. Patient #24 had a start of care date of 12/7/2020 and transferred from agency services on 12/29/2020. Review of the clinical record revealed the following: a. The POC, dated 12/7/2020 to 2/4/2021, included physician orders for skilled nursing 2 times per week and home health aide services 3 times per week for 8 weeks. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care, dated 12/7/2020, identified the patient had diagnoses of schizoaffective disorder, Alzheimer's, diabetes and abnormalities of gait and mobility. The assessment identified the patient had a stage 4 pressure ulcer (deep pressure injury reaching into muscle and bone), was a fall risk with poor balance and muscle weakness, absence of capable caregiver, incontinent of urine, constantly confused, oriented to person, forgetful, activity intolerance, difficulty breathing with moderate exertion, required assistance with upper body dressing, set up assistance with grooming and lower body dressing and intermittent assistance with showering. c. The home health aide care plan, dated 12/9/2020, included RN instructions to the home health aide to complete the following personal care tasks: chair bath, shower, shower with chair, assist with dressing, lotion, oral care, encourage fluids and remind to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 12/9, 12/10, 12/14, 12/16 and 12/21/2020, lacked documentation or a reason why the home health aide failed to complete assigned tasks per the home health aide care plan (see G0800). e. The week of 12/20/2020 included documentation of 2 missed home health aide visits, dated 12/23 and 12/25. The missed home health aide visit note, dated 12/23, included documentation the Administrator/Clinical Manager completed the form and documented the reason for the missed visit as "patient/family uncooperative". The missed home health aide visit note, dated 12/25, included documentation Staff J, Home Health Aide, completed the missed visit form and documented the reason as "canceled". f. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services as scheduled during the week of 12/20/2020. Agency staff failed to provide home health services according to the plan of care, failed to notify patients of the inability to provide services as ordered resulting in a lack of coordination in the delivery of care. 20. Patient #25 had a start of care date of 8/26/2020 and transferred from agency services on 1/20/21. Review of the clinical record revealed the following: a. The POCs, dated 8/26/2020 to 10/24/2020 and 10/25/2020 to 12/23/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care by Staff G, RN, dated 8/26/2020, identified the patient had respiratory failure, absence of a capable caregiver, difficulty breathing and used oxygen, was incontinent of urine, oriented to person and place, forgetful, a fall risk with poor balance, unsteady gait and muscle weakness, required set up assistance with grooming and bathing and intermittent assistance with showering. c. The home health aide care plan (titled homemaker care plan in the electronic system), dated 8/26 and 10/21/2020, included RN instructions to the home health aide to complete the following personal care tasks: record the patient's last bowel movement, meal set up, limit fluids, assist with ambulation, assist with transfer and remind the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services, dated 11/5, 11/12, 11/19, 11/25 and 12/3/2020, lacked documentation or a reason why the home health aide failed to complete assigned tasks per the home health aide care plan (see G0800). e. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion by Staff C, LPN, dated 12/11/2020. Staff C, LPN, documented she supervised Staff I, Home Health Aide, and Staff I failed to maintain open communication with the patient, failed to arrive for assigned visits as scheduled, failed to follow the care plan for completion of assigned tasks, failed to competently complete assigned tasks and failed to honor patient rights. See G478 interview on 2/16/21 at 12:03 PM with Staff G, RN. See G478 interview on 2/16/21 at 12:32 PM with Staff D, RN. See G478 interview on 2/16/21 at 2:25 PM with Staff C, LPN. The complaint log and clinical record lacked any documentation of an existence, investigation or resolution of the patient's complaints of not receiving care and services to meet the needs of the patient. Agency staff were aware of the patient's complaints for an indeterminate amount of time and placed the patient in a position to suffer further violations of lack of care. Agency staff failed coordinate the delivery of care. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, patient, family and staff interviews, the agency failed to ensure agency home health aides followed the care plan to meet the assessed needs of the patients (G0800) The systemic practice identified the agency's failure to have a process in place to ensure agency staff met the needs of the agency's 98 patients receiving home health aide service.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient, family and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 21 of 24 sampled patients receiving home health aide services (Patients #1, #2, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26). The agency reported a current census of 150 patients at the time of the survey, including 98 who received care provided by a home health aide. Failure to ensure agency staff provided home health aide services as ordered by the physician and according to the home health aide care plan increased resulted in patients' personal care needs not being adequately met. Findings include: Review of the agency's undated policy, titled Implementing Care and Treatment, identified the RN will oversee the assignment of the home health aide in particular and prepare written instructions for the home health aide to follow. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 9/1/2020 to 10/30/2020 and 10/31/2020 to 12/29/2020, identified diagnoses of chronic obstructive pulmonary disease, diabetes, multiple sclerosis and heart failure. The POCs included physician orders for skilled nursing services 2 times per week and home health aide services 3 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The home health aide care plans, dated 9/1 and 10/31/2020, included registered nurse (RN) instructions to the home health aide to complete the following personal care tasks: provide bed bath, assist with dressing, apply lotion to the skin, comb hair, oral care, clean/file nails, incontinence care, record last bowel movement, encourage fluids, turn and reposition and remind the patient to take medications every visit and then shampoo hair weekly. c. The update to the comprehensive assessment completed at the time of recertification, dated 10/29/2020, identified the patient had difficulty breathing with minimal exertion, was incontinent of bowel and bladder, limited range of motion in the lower extremities, was totally dependent on someone to assist with dressing and bathing and was bedfast. d. The home health aide visit notes, dated 10/16, 11/2, 11/9, 11/20, 11/23 and 11/27/2020, included documentation the home health aide completed the tasks of encouraging fluids, turn and position and provide a medication reminder. The home health aide failed to document if she completed the tasks of bed bath, assist with dressing, apply lotion to the skin, comb hair, oral care, clean/file nails, incontinence care, record last bowel movement and shampoo hair, or a reason why the home health aide failed to complete the assigned tasks. e. The home health aide visit note, dated 10/19/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, apply lotion to the skin, comb hair, clean/file nails, encourage fluids, turn and reposition and shampoo hair. The home health aide failed to document if she completed the tasks of oral care, incontinence care, record last bowel movement and remind the patient to take medication, or a reason why the home health aide failed to complete the assigned tasks. f. The home health aide visit note, dated 10/21/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, apply lotion to the skin, comb hair, clean/file nails, encourage fluids, turn and reposition, oral care and shampoo hair. The home health aide failed to document if she completed the tasks of incontinence care and record last bowel movement, or a reason why the home health aide failed to complete the assigned tasks. g. The home health aide visit note, dated 11/16/2020, included documentation the home health aide completed the tasks of apply lotion, clean/file nails, encouraging fluids, turn and position and provide a medication reminder. The home health aide failed to document if she completed the tasks of bed bath, assist with dressing, comb hair, oral care, incontinence care, record last bowel movement and shampoo hair, or a reason why the home health aide failed to complete the assigned tasks. h. The home health aide visit note, dated 11/18/2020, included documentation the home health aide completed the tasks of bed bath, apply lotion, clean/file nails, encouraging fluids, turn and position and provide a medication reminder. The home health aide failed to document if she completed the tasks of assist with dressing, comb hair, oral care, incontinence care, record last bowel movement and shampoo hair, or a reason why the home health aide failed to complete the assigned tasks. i. The home health aide visit note, dated 11/25/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, apply lotion to the skin, clean/file nails, encourage fluids, turn and reposition, record last bowel movement, remind to take medications. The home health aide failed to document if she completed the tasks of comb hair, oral care, shampoo hair and incontinence care, or a reason why the home health aide failed to complete the assigned tasks. j. The home health aide visit note, dated 11/30/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, apply lotion to the skin, shampoo, comb hair, oral care, clean/file nails, incontinence care, record last bowel movement, turn and reposition and remind the patient to take medications. The home health aide failed to document if she completed the task of encourage fluids and documented completing an additional unassigned task of range of motion on the patient. k. The home health aide visit note, dated 12/2 and 12/11/2020, included documentation the home health aide completed the tasks of record last bowel movement, encouraging fluids, turn and position and provide a medication reminder. The home health aide failed to document if she completed the tasks of bed bath, assist with dressing, comb hair, oral care, incontinence care, apply lotion, clean/file nails and shampoo hair, or a reason why the home health aide failed to complete the assigned tasks. l. The home health aide visit note, dated 12/4 and 12/9/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, apply lotion , encourage fluids, turn and reposition, record last bowel movement and remind to take medications. The home health aide failed to document if she completed the tasks of comb hair, oral care, clean/file nails, shampoo hair and incontinence care, or a reason why the home health aide failed to complete the assigned tasks. m. The home health aide visit note, dated 12/7 and 12/14/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, apply lotion, shampoo hair, encourage fluids, turn and reposition, record last bowel movement and remind to take medications. The home health aide failed to document if she completed the tasks of comb hair, oral care, clean/file nails and incontinence care, or a reason why the home health aide failed to complete the assigned tasks. On 2/8/21 at 3:49 PM, during an interview, Staff I, Home Health Aide, reported she was told to put refuse if she was unable to complete an assigned task. On 2/9/11 at 11:38 AM, during a phone interview, the patient reported he/she and live-in family member were always home when agency scheduled the home health aide to come to the home to provide services, and the patient denied refusing any services. The patient reported the home health aide did not show up to provide cares. n. The Home Health Aide Supervisory Visit notes, dated 10/26, 11/9, 11/23, 12/7 and 12/21/2020, included a signature of completion by Staff C, Licensed Practical Nurse (LPN), and all identified the home health aide was not arriving for visits as scheduled. In addition, the notes, dated 11/23, 12/7 and 12/21, identified the home health aide was not providing care according to the care plan, not performing tasks competently and not honoring the patient's rights. On 2/9/21 at 1:27 PM, during an interview, Staff C, LPN, explained when she supervises home health aide services, she asks if the home health aide is showing up as scheduled and if they are doing a good job; she does not review home health aide documentation. She reported all of the information in the Home Health Aide Supervisory visit notes came from interviews with Patient#1 and the patient complained every time of Staff I, Home Health Aide not showing to provide services. Staff C, LPN, reported she told Staff D, Registered Nurse (RN), one time and told the Administrative Assistant a couple times. She clarified and explained she reported each time the patient complained. The home health aide failed to provide patient cares according to the home health aide care plan. 2. Patient #2 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POC, dated 10/30/2020 to 12/28/2020 and 12/29 to 2/26/2020, identified diagnoses of hypertension, diabetes, orthostatic hypotension (drop in blood pressure with position change, usually lying or sitting to standing and can cause dizziness or lightheadedness) and Parkinson's Disease and included orders for skilled nursing services 1 time per week and home health aide services 2 times per week. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/25/2020, identified the patient was a fall risk, had difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, oriented to person and place, required prompting if in stressful or new situations, required set-up assistance for grooming, toilet hygiene and dressing, but required assistance or supervision to bathe. c. The home health aide care plans, dated 9/3, 10/28 and 12/25/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, encourage fluids and remind the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/26 through 12/21/2020. e. The home health aide visit notes, dated 10/26, 10/30, 11/3, 11/6, 11/10, 11/12, 11/16, 11/19, 11/23, 11/26, 11/30, 12/5, 12/8, 12/10, 12/14, 12/17 and 12/21/2020, included documentation the home health aide encouraged the patient drink fluids and reminded the patient to take medications. The home health aide failed to document if she completed the tasks of showering with a chair and assisting the patient with dressing, or a reason why the home health aide failed to complete the assigned tasks. f. The Home Health Aide Supervisory visit notes, dated 11/4, 11/19, 12/3 and 12/17/2020, included documentation by Staff E, RN, which identified the home health was following the aide care plan and completing the assigned tasks. On 2/9/21 at 9:25 AM, during an interview, the patient reported Staff I, Home Health Aide, told the patient she did not have time to help the patient with a shower. The patient reported he/she needed help with a shower and did not get the help and services the patient needed. The patient reported the patient did not tell anybody about not getting help with showering. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, explained she interviews the patient when supervising the home health aide. She will ask the patient about communication, if the home health aide is providing services as scheduled and following the care plan. She denied Patient #2 ever complained about home health aide services provided by Staff I, Home Health Aide. She does not review home health aide documentation when supervising the home health aide. The home health aide failed to provide services according to the care plan. 3. Patient #7 had a start of care date of 9/28/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/28/2020 to 11/26/2020 and 11/27/2020 to 1/25/2020, included orders for skilled nursing and home health aide services. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The comprehensive assessment completed at the start of care, dated 9/28/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 11/23/2020, identified the patient was a fall risk, had a lack of caregiver/family support, a fall risk, incontinent of urine, poor balance, muscle weakness, difficulty breathing with moderate exertion, required set up assistance with grooming and intermittent assistance with bathing. c. The home health aide care plans, dated 9/30, 11/23 and 11/27/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower, assist with dressing, apply lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfers, remind the patient to take medications every visit, and then clean/file nails and shave weekly. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/8 through 12/17/2020. e. The home health aide visit notes, dated 10/8 and 10/22/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation or a reason why the home health aide failed to complete the assigned personal care tasks (shower, assist with dressing, apply lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfers, remind the patient to take medications every visit, and then clean/file nails and shave weekly). f. The home health aide visit notes, dated 10/15 and 10/21/2020, included documentation the home health aide completed the tasks of meal set up and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. g. The home health aide visit notes, dated 10/27, 10/30 and 11/3/2020, included documentation the home health aide completed the task of encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. h. The home health aide visit note, dated 11/6/2020, included documentation the home health aide completed the task of reminding the patient to take medications, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. i. The home health aide visit notes, dated 11/10, 11/17, 11/20 and 11/24/2020, included documentation the home health aide completed the tasks of reminding the patient to take medications and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. j. The home health aide visit notes, dated 11/28, 12/1, 12/5, 12/8, 12/11, 12/15 and 12/17/2020, included documentation the home health aide completed the tasks of reminding the patient to take medications, encourage fluids and recording the patient's last bowel movement, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. k. The Home Health Aide Supervisory visit notes, dated 10/13, 10/26 and 11/19/2020, included documentation Staff G, RN, supervised Staff L, Home Health Aide, and determined the home health aide had followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. The clinical record lacked documentation Staff L had provided any home health aide services in the home. l. The Home Health Aide Supervisory visit note, dated 11/24/2020, included documentation Staff C, LPN, had supervised a home health aide (did not designate a specific home health aide) and included documentation the home health aide followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. m. The Home Health Aide Supervisory visit notes, dated 12/1 and 12/15/2020, included documentation Staff C, LPN, supervised Staff M, Home Health Aide, and included documentation the home health aide had followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. The clinical record lacked documentation Staff M had provided any home health aide services in the home. The home health aide failed to provide services according to the care plan. 4. Patient #8 had a start of care date of 8/27/2020. Review of the clinical record revealed the following: a. The POC, dated 8/27/2020 to 10/25/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The POC, dated 10/26/2020 to 12/24/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week for 5 weeks, 1 time per week for 1 week, and no home health aide services the last 3 weeks of the certification period. c. The comprehensive assessment completed at the start of care, dated 8/27/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 10/21/2020, identified the patient did not have a capable caregiver, was a fall risk, had difficulty breathing with minimal exertion, used 4 liters of oxygen per minute per nasal cannula, required prompts or became confused if new or stressful situations, forgetful, muscle weakness, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. d. The home health aide care plans, dated 8/28 and 10/23/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. e. The clinical record included documentation of completed and missed home health aide visits by Staff I, former Home Health Aide, dated 10/14 to 11/30/2020. f. The home health aide visit notes, dated 10/14, 11/2, 11/16 and 11/23/2020, included documentation the home health aide completed the task of reminding the patient to take medications, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. g. The home health aide visit notes, dated 10/19 and 10/21/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation or a reason why the home health aide failed to complete the assigned personal care tasks (shower, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly). h. The home health aide visit notes, dated 11/9, 11/11, 11/18 and 11/25/2020, included documentation the home health aide completed the tasks of reminding the patient to take medications and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. i. The home health aide visit note, dated 11/30/2020, included documentation the home health aide completed the tasks of reminding the patient to take medications, encourage fluids and recording the patient's last bowel movement, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. On 2/9/21 at 1:40 PM, during an interview, the patient reported Staff I, Home Health Aide, only showed up 2 times between October and the end of November 2020. The patient reported the 2 times Staff I, Home Health Aide, did show up, she only sat on the patient's couch and did not do anything. The patient explained after the first time the home health aide did not do anything, the patient told Staff D, RN. The patient reported telling Staff D, RN, again after Staff I, Home Health Aide, showed up the second time and did not do anything. The patient was not sure on the dates, but reported the patient knew the patient had told Staff D, RN, sometime prior to stopping home health aide services. j. An interim physician order, dated 12/2/2020, included orders to discontinue home health aide services per the patient's request. On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, reported she remembered the patient complaining Staff I, Home Health Aide, was not showing up and asked to discontinue services. k. The Home Health Aide Supervisory visit notes, dated 10/28, 11/11, 11/25 and 12/2/2020, included documentation Staff D, RN, completed the note and documented the home health aide followed the patient's care plan, arrived for visits as scheduled, maintains open communication with the patient and honored the patient's rights. 5. Patient #9 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. A patient signed consent form for care and services, signed by the patient and agency staff on 11/9/2020, identified the agency planned to provide skilled nursing, home health aide and physical therapy services. b. The POC, dated 11/9/2020 to 1/7/2021, identified a diagnosis of fracture of the first lumbar vertebra and included orders for skilled nursing 1 time per week, home health aide services 2 times per week and physical therapy services 1 time the first week and then 2 times for 3 weeks. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. c. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient suffered from lower back pain with an intensity of 3 to 10 (with 10 the worst) all the time, occasional incontinence, at risk for falls, oriented to person and place, forgetful, but lacked a memory deficit, confused in new or complex situations, required assistance with set up for grooming and upper body dressing, dependent on assistance for lower body dressing, unable to shower without assistance, unable to maintain toilet hygiene and transfer without assistance and chairfast, but able to wheel self independently. d. The home health aide care plan, dated 11/10/2020, included RN instructions to the home health aide to complete the following personal care tasks: chair bath, tub bath, shower with chair, assist with dressing, lotion, shampoo hair, assist to toilet and incontinence care. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 11/19 through 12/16/2020. f. The home health aide visit notes, dated 11/19, 11/23, 11/25, 11/30, 12/3, 12/7, 12/10 (documented on two different days and 2 different notes for the same day) and 12/16/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks or a reason why the aide failed to complete the assigned tasks. g. On 2/10/21 at 2:09 PM, during an interview, the patient reported she/he had not wanted home health aide or homemaker services. The patient reported she/he had been able to meet her own needs including showering independently. The patient told the nurse Staff H, RN, the patient did not want anyone else coming into the home. The patient denied receiving services from any agency staff person with the exception of Staff H, RN. On 2/16/21 at 12:17 PM, during an interview, Staff H, RN, reported the patient was confusing. The patient agreed to home health aide services at first due to lower back pain and safety concerns, but refused visits after the first 1 to 2 times. Staff H, RN, reported the patient agreed to accept the service when asked again. Staff H, RN, was not sure if the patient had let anyone provide home health aide services. Staff H, RN, reported she supervises the home health aides by asking the patient if the home health aide is following the care plan, reviews the tasks on the care plan with the patient to ensure the home health aide is following the plan, ask if the patient is satisfied, and, on occasion if the home health aide is new, review the home health aide's documentation. 6. Patient #10 had a start of care date of 7/21/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/19/2020 to 11/17/2020 and 11/18/2020 to 1/16/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The home health aide care plans, dated 9/19 and 11/18/2020, included RN instruction to the home health aide to complete the following personal care tasks: chair bath, assist with dressing, lotion, comb hair, shampoo, oral care, clean dentures, assist to bedside commode, incontinence care, record last bowel movement, meal set up, assist with ambulation, assist with transfers and remind the patient to take medications every visit and clean/file nails and shave weekly. c. The update to the comprehensive assessments completed at the time of recertification, dated 9/17 and 11/17/2020, identified the patient had chronic respiratory failure, the patient's caregiver suffered from burnout incontinence of urine, activity intolerance, suffered from dizziness, oriented to person and place but forgetful, required set up assistance with dressing and toilet hygiene and required assistance for bathing. d. The home health aide visit note, dated 10/9/2020, included documentation the home health aide completed the tasks of chair bath, assist with dressing, lotion, comb hair and shampoo hair, but lacked documentation or a reason why she failed to complete the assigned tasks of oral care, clean dentures, assist to bedside commode, incontinence care, record last bowel movement, meal set up, assist with ambulation, assist with transfers and remind the patient to take medications. e. The home health aide visit note, dated 11/17/2020, included documentation the home health aide completed the task of encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. f. The home health aide visit note, dated 11/19/2020, included documentation the home health aide completed the tasks of chair bath, assist with dressing, lotion, encourage fluids and remind the patient to take medications, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. g. The home health aide visit note, dated 11/24/2020, included documentation the home health aide completed the tasks of chair bath, assist with dressing, lotion, comb hair and shampoo hair, record last bowel movement, encourage fluids and remind patient to take medications, but lacked documentation or a reason why she failed to complete the assigned tasks of oral care, clean dentures, assist to bedside commode, incontinence care, meal set up, assist with ambulation and assist with transfers. h. The home health aide visit note, dated 11/27/2020, included documentation the home health aide completed the tasks of chair bath, assist with dressing, lotion, record last bowel movement, encourage fluids and remind patient to take medications, but lacked documentation or a reason why she failed to complete the other assigned tasks. i. The Home Health Aide Supervisory visit notes, dated 10/19, 11/2, 11/16, 11/19, 12/3, 12/17, 12/31/2020, included documentation Staff C, LPN, supervised only Staff N, Home Health Aide. The home health aide failed to provide services according to the care plan. 7. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: a. The POC, dated 10/9/2020 to 12/7/2020, included orders for home health aide services 2 times per week and skilled nursing services weekly. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The POC, dated 12/8/2020 to 2/5/2021, included orders for skilled nursing and home health aide services 1 time per week. c. The update to the comprehensive assessment completed at the time of recertification, dated 10/5/2020, identified the following: a primary diagnosis of Parkinson's Disease, absence of a capable caregiver, fall risk, difficulty breathing with moderate exertion, activity intolerance, incontinent of urine, oriented to person and place, forgetful, poor balance, muscle weakness, unsteady gait, required set up assistance with dressing, grooming and toilet hygiene and needed intermittent assistance with showering. d. The home health aide care plans, dated 10/6 and 12/8/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/20 through 12/18/2020. f. The home health aide visit note, dated 10/20/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks(shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly). g. The home health aide visit note, dated 11/6 and 11/13/2020, included documentation the home health aide completed the task of encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. h. The home health aide visit note, dated 11/10, 11/17, 12/9 and 12/18/2020, included documentation the home health aide completed the tasks of encourage fluids and remind the patient to take medications, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. i. The home health aide visit note, dated 11/24/2020, included documentation the home health aide completed the tasks of reminding the patient to take medications, encourage fluids and recording the patient's last bowel movement, but lacked documentation or a reason why the home health aide failed to complete the other assigned tasks. j. The Home Health Aide Supervisory visit notes, dated 11/9, 11/23, 12/7 and 12/21/2020, included documentation Staff E, RN, supervised Staff I, Home Health Aide, and documented the home health aide followed the care plan to complete tasks. The home health aide failed to provide services according to the care plan. 8. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POC, dated 8/31/2020 to 10/29/2020, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. An interim physician order, dated 9/21/2020, included an order to increase home health aide services to 3 times per week. c. The POC, dated 10/30/2020 to 12/28/2020, included an order for home health aide services 1 time the first week and then 2 times per week. d. The update to the comprehensive assessment completed at the time of recertification, dated 12/28/2020, identified the patient had a diagnosis of chronic obstructive pulmonary disease, was a fall risk, caregiver burnout, oriented to person and place, forgetful, difficulty breathing with minimal exertion, activity intolerance, urinary incontinence, poor balance, muscle weakness, required set up assistance with grooming and dressing and intermittent assistance with bathing. e. The home health aide care plans, dated 9/8 and 10/29/2020, included RN instructions to the home health aide to complete the following personal care tasks: tub bath, assist with dressing, lotion and remind the patient to take medications. f. The home health aide visit notes, dated 10/9, 10/12, 10/14, 10/19, 10/21, 10/23, 10/26, 10/30 and 11/16/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks (tub bath, assist with dressing, lotion and remind the patient to take medications), or a reason why the home health aide failed to complete the assigned tasks. g. The home health aide visit notes, dated 10/16, 10/28, 11/2, 11/4, 11/9, 11/11,11/23, 11/25 and 11/27/2020, included documentation the home health aide completed the task of reminding the patient to take medication, but lacked documentation the home health aide completed the other assigned tasks, or a reason why the home health aide failed to complete the rest of the assigned tasks. h. The Home Health Aide Supervisory visit notes, dated 10/30, 11/13, 11/27 and 12/11/2020, included documentation Staff C, LPN, had supervised the home health aide and documented the home health aide followed the care plan, arrived for visits as scheduled, demonstrated competency and honored patient rights. On 2/10/21 at 12:48 PM, during an interview, the patient reported he/she had not refused or canceled any services the end of November through 12/9/2020. The patient reported Staff I, Home Health Aide, would come to the patient's home, do one task and then get on her phone. The patient reported Staff I, Home Health Aide, never offered to assist the patient with bathing, dressing or applying lotion, and she never reminded the patient to take medications. The patient reported he/she told Staff I, former Home Health Aide, to not come back after 4 weeks due to mishandling and haphazardly storing some glass Halloween decorations and almost ruining the patient's carpet. The patient reported the patient called the agency and complained about Staff I, Home Health Aide. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported the patient had complained to her about Staff I, former Home Health Aide, not doing assigned tasks. 9. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The updates to the comprehensive assessment completed at the time of recertification, dated 10/20 and 12/21/2020, identified the patient was at risk for falls, activity intolerance, poor balance, muscle weakness, unsteady gait, difficulty breathing with moderate exertion, bladder incontinence, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. c. The home health aide care plans, dated 8/24, 10/21 and 12/21/2020, included RN instructions to the home health aide to complete the following personal care task: record the patient's last bowel movement. d. The home health aide visits, dated 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23 and 12/11/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed the assigned personal care task, or a reason why the home health aide failed to complete the assigned task. e. The home health aide visit, dated 12/7/2020, included documentation of a signature of completion, but lacked documentation of the completion of any tasks, or a reason why the home health aide failed to do any tasks. f. The Home Health Aide Supervisory visit note, dated 10/30/2020, completed by Staff Q, LPN, included documentation she had supervised the home health aide and documented the home health aide was not maintaining open communication, not arriving for visits as scheduled, not following the care plan and not demonstrating competency in completing tasks. Staff Q documented this as an issue with how the patient wanted the house cleaned. g. The Home Health Aide Supervisory visit notes, dated 11/10, 12/8 and 12/21/2020, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication, arrived for visits as scheduled, followed the care plan and completed tasks competently. On 2/10/21 at 3:15 PM, during an interview, the patient reported he/she remembered Staff I, Home Health Aide. The patient did not write down dates, but reported Staff I, Home Health Aide, came on Mondays and Fridays the times she did show up. The patient reported Staff I, Home Health Aide, never asked the patient about the patient's bowel movements. The patient reported none of the current staff have ever done this either. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, reported the patient had complained to her several times about Staff I, Home Health Aide, not showing up. Staff E, RN, reported the patient was cognitive and able to state the home health aide had not been coming to provide services. 10. Patient #15 had a start of care date of 9/17/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/17/2020 to 11/15/2020 and 11/16/2020 to 1/14/2021, included physician orders for skilled nursing and home health aide services 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The comprehensive assessment completed at the start of care, dated 9/17/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 11/12/2020, identified the patient had chronic obstructive pulmonary disease, diabetes, was a fall risk, had difficulty breathing, used 3 liters of oxygen per minute, activity intolerance, poor balance, absence of a capable caregiver, incontinent of urine, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and required intermittent assistance with bathing. c. The home health aide care plans, dated 9/17, 11/3 and 11/16/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The clinical record included documentation Staff I, former Home Health Aide, provided home health aide visits, dated 10/9 to 12/18/2020. e. The week of 10/4 included documentation of 2 home health aide visit notes, dated 10/6 and 10/9/2020. The visit note, dated 10/6, included documentation the tasks of clean/file nails and shaving were "NA" (not applicable). The visit note, dated 10/9, included documentation the home health aide only encouraged fluids, and lacked documentation why the home health aide failed to complete the rest of the assigned tasks. f. The week of 10/11 included documentation of 2 home health aide visit notes, dated 10/14 and 10/16/2020. The visit note, dated 10/14, lacked documentation the home health aide completed the task of reminding the patient to take medications and lacked a reason why the home health aide failed to complete the assigned task. The home health aide documented the patient refused shaving and clean/file nails. The home health aide visit note, dated 10/16/2020, included documentation the home health completed the tasks of meal set up and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. g. The home health aide visit notes, dated 10/21 and 11/10/2020, included documentation the home health aide only encouraged fluids, and lacked documentation why the home health aide failed to complete the rest of the assigned tasks. h. The home health aide visit note, dated 10/28/2020, included documentation the home health completed homemaker tasks only and no personal care tasks. The visit note lacked a reason why the home health aide failed to complete the assigned tasks. i. The home health aide visit note, dated 11/3/2020, included documentation the home health completed the tasks of meal set up and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. j. The home health aide visit note, dated 11/6/2020, included documentation the home health completed the tasks of meal set up, remind the patient to take medications and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. k. The home health aide visit notes, dated 11/13, 11/17, 11/20, 11/24 and 11/27/2020, included documentation the home health completed the tasks of reminding the patient to take medications and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. l. The home health aide visit notes, dated 12/1, 12/4, 12/8, 12/15 and 12/18/2020, included documentation the home health completed the tasks of record patient's last bowel movement, remind the patient to take medications and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. m. The home health aide visit note, dated 12/11/2020, included documentation the home health completed the tasks of meal set up, record the patient's last bowel movement, remind the patient to take medications and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. n. The Home Health Aide Supervisory visit notes, dated 10/13 and 10/27/2020, completed by Staff Q, LPN, included documentation she had supervised the home health aide and documented the home health aide followed the care plan. o. The Home Health Aide Supervisory visit notes, dated 11/10, 11/24, 12/8 and 12/22/2020, included documentation Staff E, RN, supervised the home health aide and documented the home health aide followed the care plan. 11. Patient #16 had a start of care date of 2/10/2020. Review of the clinical record revealed the following: a. The POC, dated 12/2/2020 to 1/30/2021, included physician orders for skilled nursing and home health aide services 2 times per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The update to the comprehensive assessment, dated 10/1/2020, identified the patient had alcoholic cirrhosis of the liver, muscle weakness and chronic obstructive pulmonary disease, was a fall risk, lack of caregiver/family support, difficulty breathing with minimal exertion, activity intolerance, incontinent of urine, oriented to person and place, forgetful, required assistance with grooming and bathing and set up assistance with dressing. c. The home health aide care plan, dated 12/1/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The home health aide visit notes, dated 12/4 and 12/14/2020, included documentation the home health completed the task of reminding the patient to take medications, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. e. The home health aide visit note, dated 12/7/2020, included documentation the home health completed the tasks of reminding the patient to take medications and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. f. The home health aide visit note, dated 12/9/2020, included documentation the home health completed the tasks of reminding the patient to take medications, meal set up and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. g. The home health aide visit notes, dated 12/16 and 12/21/2020, included documentation the home health completed the tasks of reminding the patient to take medications, record the patient's last bowel movement and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. h. The Home Health Aide Supervisory visit note, dated 12/15/2020, completed by Staff C, LPN, documented she supervised Staff I, former Home Health Aide, and that Staff I maintained open communication with the patient, arrived for visits as scheduled, followed the care plan and demonstrated competency with tasks performed. On 2/11/21 at 10:21 AM, during an interview, the patient reported Staff I, Home Health Aide, would say she was going to show up and then would not come. The patient clarified Staff I, Home Health Aide, did show up some of the times. The patient complained Staff I, Home Health Aide, would not do a good job when she did show up. The patient reported he/she complained to the office staff and requested a new home health aide some time around Christmas, but the patient was not sure of the exact date. On 2/17/21 at 3:16 PM, during an interview, the Administrator reported if a home health aide is unable to complete an assigned task, the home health aide needed to document the reason why. 12. Patient #17 had a start of care date of 11/30/2020 and transferred from agency services on 1/14/21. Review of the clinical record revealed the following: a. The POC, dated 11/30/2020 to 1/28/2021, included orders for skilled nursing services 2 times the first week and then 1 time per week for 8 weeks and an order for home health aide services 2 times per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. b. The comprehensive assessment completed at the start of care, dated 11/30/2020, identified the patient had heart failure and respiratory failure, absence of a capable caregiver, difficulty breathing with minimal exertion, incontinent of urine, oriented to person and place, forgetful, a fall risk, poor balance, muscle weakness, required set up assistance with upper body dressing and grooming, assistance with lower body dressing and intermittent assistance with bathing. c. The home health aide care plan, dated 11/30/2020, included RN instructions to the home health aide to complete the following personal care tasks: provide bed bath, assist with dressing, apply lotion to the skin, comb hair, incontinence care, record last bowel movement, encourage fluids, assist with ambulation and remind the patient to take medications every visit and clean/file nails weekly. d. The home health aide visit note, dated 12/2/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, applying lotion, encourage fluids and remind the patient to take medications, but lacked documentation the home health aide completed the other assigned tasks or a reason why the home health aide failed to complete the tasks. e. The home health aide visit note, dated 12/7/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, applying lotion, comb hair, record patient's last bowel movement, encourage fluids and remind the patient to take medications, but lacked documentation the home health aide completed the other assigned tasks or a reason why the home health aide failed to complete the tasks. f. The home health aide visit note, dated 12/10/2020, included documentation the home health aide completed the tasks of bed bath, assist with dressing, applying lotion, record patient's last bowel movement, encourage fluids and remind the patient to take medications, but lacked documentation the home health aide completed the other assigned tasks or a reason why the home health aide failed to complete the tasks. g. The week of 1/3/21 included documentation of 2 home health aide visits, dated 1/5 and 1/8. The home health aide visit note, dated 1/5/21, included documentation the patient had refused to let the home health aide clean/file the patient's nails. The home health aide visit note, dated 1/8/21, included documentation the task clean/file nails was "NA". The home health aide failed to offer to complete the task of clean/file nails on 1/8/21 in order to follow the home health aide care plan and complete the task weekly. h. The Home Health Aide Supervisory visit note, dated 12/9/2020, included documentation Staff E, RN, supervised the home health aide, and documented the home health aide followed the care plan. 13. Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: a. The POCs, dated 8/17/2020 to 10/15/2020, 10/16/2020 to 12/14/2020 and 12/15/2020 to 2/12/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self care. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/14/2020, identified the patient had chronic kidney failure, atrial fibrillation, did not have a capable caregiver, was short of breath with moderate exertion, had fatigue and weakness, incontinent of urine, at risk for falls, poor balance, unsteady gait, oriented to person and place, forgetful, required set up assistance with grooming and dressing and intermittent assistance with bathing. c. The home health aide care plans, dated 8/17, 10/14 and 12/14/2020, included RN instructions to the home health aide to complete the following personal care tasks: limit fluids and remind the patient to take medications. d. The home health aide visit note, dated 10/9/2020, included documentation the home health aide completed homemaker tasks, but none of the assigned personal care tasks, or a reason why the home health aide failed to complete the assigned tasks. e. The home health aide visit note, dated 10/14, 10/20, 10/28, 10/30, 11/4, 11/6, 11/10, 11/13, 11/17, 11/20, 11/25, 11/27, 12/1, 12/4, 12/8, 12/11, 12/16 and 12/18/2020, included documentation the home health aide completed the tasks of reminding the patient to take medications, but failed to include documentation of a reason why the home health aide failed to complete the assigned task of limiting fluids. f. The Home Health Aide Supervisory visit notes, dated 10/20 and 11/3/2020, included documentation Staff C, LPN, supervised the home health aide, and documented the home health aide followed the care plan. g. The Home Health Aide Supervisory visit notes, dated 11/17 and 12/1/2020, included documentation Staff E, RN, supervised the home health aide, and documented the home health aide followed the care plan. 14. Patient #19 had a start of care dare of 10/8/2020 and transferred from agency services on 10/27/2020. Review of the clinical record revealed the following: a. The POC, dated 10/8/2020 to 12/6/2020, included physician orders for skilled nursing 1 time per week and home health aide services 0 times the first week and then 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self care. The POC identified the patient was a fall risk, had vision and hearing deficits, difficulty breathing with minimal exertion, incontinent of urine, assistance with ambulation and used a walker. b. The comprehensive assessment completed at the start of care, dated 10/8/2020, identified the patient was oriented to person and place, was forgetful, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. b. The home health aide care plan, dated 10/12/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, shampoo hair, oral care, encourage fluids and remind the patient to take medications. c. The home health aide visit notes, dated 10/16 and 10/19/2020, included documentation the home health aide completed the tasks of shower with chair, assist with dressing, shampoo hair and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the assigned tasks of oral cares and reminding the patient to take medications. d. The home health aide visit notes, dated 10/21 and 10/27/2020, included documentation the home health aide completed the tasks of shower with chair, assist with dressing, shampoo hair, remind the patient to take medications and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete the assigned task of oral cares. e. The Home Health Aide Supervisory visit note, dated 10/21/2020, included documentation Staff D, RN, supervised the home health aide, and documented the home health aide followed the care plan. 15. Patient #20 had a start of care date of 10/16/2020 and discharged from agency services on 12/7/2020. Review of the clinical record revealed the following: a. The POC, dated 10/16/2020 to 12/14/2020, identified diagnoses of urinary tract infection and dementia with behavioral disturbance and included physician orders for home health aide services 2 times per week and skilled nursing services 1 time the first week, 2 times per week for 2 weeks and 1 time per week for 6 weeks. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self care. b. The comprehensive assessment completed at the start of care, dated 10/16/2020, identified the patient required 24 hour supervision, had difficulty breathing with moderate exertion, activity intolerance, fatigue/weakness, oriented to person and place, forgetful, with increased episodes of severe confusion, impaired decision making, verbally disruptive, at risk for falls, poor balance, unsteady gait, required assistance for grooming, dressing, toilet hygiene and bathing. c. The home health aide care plan, dated 10/16/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, clean dentures, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. d. The home health aide visit note, dated 10/20/2020, included documentation the home health aide completed the assigned tasks of meal set up and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete any of the other assigned tasks. e. The home health aide visit notes, dated 10/22, 10/29, 11/3, 11/5, 11/9/2020, included documentation the home health aide completed the assigned task of encourage fluids, but lacked documentation or a reason why the home health aide failed to complete any of the other assigned tasks. f. The home health aide visit notes, dated 10/27, 11/17 and 11/19/2020, included documentation the home health aide completed the assigned tasks of reminding the patient to take medications and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete any of the other assigned tasks. g. The home health aide visit note, dated 11/12/2020, included documentation the home health aide completed the assigned task of reminding the patient to take medications, but lacked documentation or a reason why the home health aide failed to complete any of the other assigned tasks. h. The home health aide visit notes, dated 11/24, 12/1 and 12/5/2020, included documentation the home health aide completed the assigned tasks of reminding the patient to take medications, recording the patient's last bowel movement and encourage fluids, but lacked documentation or a reason why the home health aide failed to complete any of the other assigned tasks. i. The Home Health Aide Supervisory visit notes, dated 10/29, 11/12 and 11/26/2020, included documentation Staff C, LPN, supervised the home health aide and documented the home health aide maintained open communication with the patient, family, caregiver, representative, arrived for assigned visits as scheduled, followed the patient's care plan and demonstrated competency with assigned tasks. On 2/11/21 at 11:29 AM, during an interview, a family member/caregiver reported not being the patient's primary caregiver, but frequently stayed with the patient during the day. The family member/caregiver explained the patient could not be left alone. The family member/caregiver reported problems with miscommunication with agency staff, no coordination of care delivery, missed home health aide visits. On 2/11/21 at 2:08 PM, during an interview, the patient's representative/family member, reported having documentation in a communication book the family made of Staff I, Home Health Aide, showing up only 3 times, dated 10/20, 10/23 and 10/26/2020, and then not showing back up. The patient's representative/family member reported Staff C, LPN, never asked how home health aide services were going. On 2/16/21 at 12:03 PM, during an interview, Staff G, RN, reported she supervises home health aides either during a routine skilled nursing visit or during the update to the comprehensive assessment at the time of recertification. She explained sometimes the home health aide is present and she will ask the patient about concerns. She will check home health aide documentation at times, but usually the Administrator reviews the documentation. Staff G, RN, explained she went out on 12/7/2020 to do a "Recert" (update to the comprehensive assessment at the time of recertification), but ended up doing a discharge. She reported the family complained Staff I, Home Health Aide, had not been showing up to provide services at that time. Staff G, RN, explained Staff C, LPN, was the patient's primary nurse, so she passed the complaint onto Staff C, LPN, and the Administrative Assistant. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported she never received any complaints about Staff I, Home Health Aide. When asked how she supervised the home health aide, she reported she asked the patient or another family member. 16. Patient #21 had a start of care date of 9/30/19 and transferred from agency services on 12/21/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/24/2020 to 11/22/2020 and 11/23/2020 to 1/21/2021, included physician orders for skilled nursing services 1 time per week and home health aide services 2 times per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self care. b. The update the comprehensive assessment completed at the time of recertification, dated 11/18/2020, identified the patient was a fall risk, had vision and hearing impairments, shortness of breath with minimal exertion, activity intolerance, fatigue/weakness, incontinent of urine, oriented to person and place, forgetful, confused, unsteady gait, poor balance, required assistance with grooming and dressing and intermittent assistance with bathing. c. The home health aide care plans, dated 9/24 and 11/23/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower, assist with dressing, comb hair, encourage fluids and remind to take medications. d. The home health aide visit notes, dated 10/19 and 11/12/2020, included documentation the home health aide completed the assigned task of encourage fluids, but lacked documentation or a reason why the home health aide failed to complete any of the other assigned tasks. e. The home health aide visit notes, dated 10/22, 10/26, 10/29, 11/2, 11/9, 11/16, 11/19, 11/23, 11/26, 11/30, 12/3, 12/7, 12/10, 12/14 and 12/17/2020, included documentation the home health completed the tasks of reminding the patient to take medications and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. f. The home health aide visit note, dated 11/5/2020, included documentation the home health completed the tasks of reminding the patient to take medications, comb hair and encourage fluids, but lacked documentation why the home health aide failed to complete the rest of the assigned tasks. g. The Home Health Aide Supervisory visit notes, dated 10/28, 11/11, 11/25 and 12/9/2020, included documentation Staff D, RN, supervised the home health aide and documented the home health aide followed the care plan. 17. Patient #22 had a start of care date of 10/5/2020 and transferred from agency services on 10/15/2020. Review of the clinical record revealed the following: a. The POC, dated 10/5/2020 to 12/3/2020, identified a diagnosis of respiratory failure and included physician orders for skilled nursing and home health aide services 1 time per week. The POCs included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self care. b. The comprehensive assessment completed at the start of care, dated 10/5/2020, identified the patient was a fall risk, on 4 liters per minute of oxygen, had difficulty breathing at rest, activity intolerance, incontinent of urine, oriented to person and place, forgetful, poor balance, muscle weakness, required set up assistance with grooming and dressing and intermittent assistance with bathing. c. The home health aide care plan, dated 10/12/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, meal set up, encourage fluids and remind the patient to take medications. d. The home health aide visit note, dated 10/8/2020, included documentation the home health aide completed the tasks of encourage fluids and remind the patient to take medication, but lacked documentation or a reason why the home health aide failed to complete the assigned tasks of shower with chair and meal set up. e. The home health aide visit note, dated 10/13/2020, included documentation the home health aide completed the tasks of encourage fluids, meal set up and remind the patient to take medication, but lacked documentation or a reason why the home health aide failed to complete the assigned task of shower with chair. f. The Home Health Aide Supervisory visit note, dated 10/14/2020, included documentation Staff Q, LPN, supervised the home health aide and documented the home health aide followed the care plan. 18. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The POC, dated 10/13/2020 to 12/11/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/9/2020, identified the patient had diabetes, high blood pressure, heart failure, was a fall risk, absence of a capable caregiver, difficulty breathing with minimal exertion, oriented to person and place, forgetful, poor balance, muscle weakness, required set up assistance for grooming and dressing and intermittent assistance for bathing. c. The home health aide care plan, dated 10/13/2020, included RN instructions to the home health aide to complete the following personal care tasks: remind the patient to take medications. d. The home health aide visit note, dated 10/23/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation or a reason why the home health aide failed to complete the assigned personal care task of reminding the patient to take medications. 19. Patient #24 had a start of care date of 12/7/2020 and transferred from agency services on 12/29/2020. Review of the clinical record revealed the following: a. The POC, dated 12/7/2020 to 2/4/2021, included physician orders for skilled nursing 2 times per week and home health aide services 3 times per week for 8 weeks. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care, dated 12/7/2020, identified the patient had diagnoses of schizoaffective disorder, Alzheimer's, diabetes and abnormalities of gait and mobility. The assessment identified the patient had a stage 4 pressure ulcer (deep pressure injury reaching into muscle and bone), was a fall risk with poor balance and muscle weakness, absence of capable caregiver, incontinent of urine, constantly confused, oriented to person, forgetful, activity intolerance, difficulty breathing with moderate exertion, required assistance with upper body dressing, set up assistance with grooming and lower body dressing and intermittent assistance with showering. c. The home health aide care plan, dated 12/9/2020, included RN instructions to the home health aide to complete the following personal care tasks: chair bath, shower, shower with chair, assist with dressing, lotion, oral care, encourage fluids and remind to take medications. d. The home health aide visit note, dated 12/9/2020, included documentation the home health aide completed the tasks of encourage fluids and remind the patient to take medications, but lacked documentation or a reason why the home health aide failed to complete the remainder of the assigned tasks. e. The home health aide visit notes, dated 12/10, 12/14, 12/16 and 12/21/2020, included documentation the home health aide completed the tasks of shower, shower with chair, assist with dressing, lotion, oral care, encourage fluids and remind to take medications, but lacked documentation or a reason why the home health aide failed to complete the task of oral care. f. The Home Health Aide Supervisory visit note, dated 12/14/2020, included documentation Staff E, RN, supervised Staff I, Home Health Aide, and documented Staff I followed the care plan to complete the tasks assigned. 20. Patient #25 had a start of care date of 8/26/2020 and transferred from agency services on 1/20/21. Review of the clinical record revealed the following: a. The POC, dated 10/25/2020 to 12/23/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care by Staff G, RN, dated 8/26/2020, identified the patient had respiratory failure, absence of a capable caregiver, difficulty breathing and used oxygen, was incontinent of urine, oriented to person and place, forgetful, a fall risk with poor balance, unsteady gait and muscle weakness, required set up assistance with grooming and bathing and intermittent assistance with showering. c. The home health aide care plan (titled homemaker care plan in the electronic system), dated 8/26 and 10/21/2020, included RN instructions to the home health aide to complete the following personal care tasks: record the patient's last bowel movement, meal set up, limit fluids, assist with ambulation, assist with transfer and remind the patient to take medications. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 11/5 to 12/3/2020. e. The home health aide visit notes, dated 11/5, 11/12, 11/19 and 11/25/2020, included documentation the home health aide completed the assigned task of reminding the patient to take medications, but lacked documentation or a reason why the home health aide failed to complete the remainder of the other assigned tasks. f. The home health aide visit note, dated 12/3/2020, included documentation the home health aide completed the assigned tasks of reminding the patient to take medications and recording the patient's last bowel movement, but lacked documentation or a reason why the home health aide failed to complete the remainder of the other assigned tasks. e. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion by Staff C, LPN, dated 12/11/2020. Staff C, LPN, documented she supervised Staff I, Home Health Aide, and Staff I failed to maintain open communication with the patient, failed to arrive for assigned visits as scheduled, failed to follow the care plan for completion of assigned tasks, failed to competently complete assigned tasks and failed to honor patient rights. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported the patient told her that Staff I, Home Health Aide, had not been coming to provide home health aide services. Staff C, LPN, reported the patient complained prior to 12/17/2020, but she was unsure of dates. Staff C, LPN, reported the patient was unable to personal cares independently. 21. Patient #26 had a start of care date of 10/1/2020 and transferred from agency services on 10/16/2020. Review of the clinical record revealed the following: a. The POC, dated 10/1/2020 to 11/29/2020, included physician orders for skilled nursing and home health aide services. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The comprehensive assessment completed at the start of care, dated 10/1/2020, identified the patient had acute respiratory failure, used oxygen, did not have a capable caregiver, had 3 open leg wounds, incontinent of urine and bowel, oriented to person and place, forgetful, a high risk for falls with poor balance, muscle weakness and an unsteady gait, required assistance with grooming and dressing and intermittent assistance with bathing. c. The home health aide care plan, dated 10/5/2020, included RN instructions to the home health aide to complete the following personal care tasks: chair bath, lotion, oral care, meal set up and encourage fluids every visit, and shave weekly. d. The home health aide visit note, dated 10/8/2020 (the only visit note for the week), included documentation Staff I, former Home Health Aide, completed the tasks of chair bath, lotion and encourage fluids, but lacked documentation or a reason why Staff I failed to complete the assigned tasks of oral care, shaving and meal set up. e. The home health aide visit note, dated 10/14/2020, included documentation Staff I, Home Health Aide, completed the tasks of lotion and encourage fluids, but lacked documentation or a reason why Staff I failed to complete the assigned tasks of chair bath, oral care and meal set up. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review, patient, family and staff interview, the agency failed to do the following: 1) ensure entries in the clinical record related to interventions provided by staff were accurate and complete (G1014); and, 2) ensure staff appropriately authenticated the completion of documentation in the clinical record (G1024). The cumulative systemic practices resulted in the failure of the agency to ensure agency staff had a process in place to accurately document care and services provided to the agency's 150 patients.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient, family, patient representative and staff interview, the agency failed to ensure the patient's clinical record included accurate and complete documentation of interventions in the patient record for 19 of 26 sampled patients (Patients #1, #2, #4, #5, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #20, #23, #25). The agency reported a census of 150 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patient's at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's undated policy, titled Medical Record Content, identified the medical record will contain complete information and accurately describes care provided. Review of the agency's complaint log on 2/8/2020 revealed the following: Patient #1 complained on 10/19/2020 and 12/22/2020 that Staff I, former Home Health Aide, was not showing up for visits. The complaint log lacked any documentation of investigation into the patient's complaints. The complaint log lacked documentation of complaints made by any other patients since 5/18/2020. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: The Plans of Care (POCs), dated 9/1/2020 to 10/30/2020 and 10/31/2020 to 12/29/2020, included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status. The home health aide care plans, dated 9/1 and 10/31/2020, included registered nurse (RN) instructions to the home health aide to complete the following tasks: provide bed bath, assist with dressing, apply lotion to the skin, comb hair, oral care, clean/file nails, incontinence care, record last bowel movement, encourage fluids, turn and reposition and remind the patient to take medications every visit and then shampoo hair weekly. The update to the comprehensive assessment completed at the time of recertification, dated 10/29/2020, identified the patient had difficulty breathing with minimal exertion, was incontinent of bowel and bladder, limited range of motion in the lower extremities, was totally dependent on someone to assist with dressing and bathing and was bedfast. a. The clinical record included documentation of missed home health aide visits notes completed by Staff I, Home Health Aide, dated 10/9, 10/12, 10/15, 10/23, 10/26, 10/30, 11/4, 11/6, 11/11, 11/13, 12/16 and 12/18/2020, for reasons of either no one answering the phone, door or the patient/family being uncooperative. 1) The home health aide visit notes, dated 10/16, 10/19, 10/21, 11/2, 11/9, 11/16, 11/18, 11/20, 11/23, 11/25, 11/27, 11/30, 12/2, 12/4, 12/7, 12/9, 12/11 and 12/14/2020, included documentation by Staff I, Home Health Aide, that she provided personal cares to the patient. 2) The Home Health Aide Supervisory Visit notes, dated 10/26, 11/9, 11/23, 12/7 and 12/21/2020, included a signature of completion by Staff C, Licensed Practical Nurse (LPN), and all identified the home health aide was not arriving for visits as scheduled. In addition, the notes, dated 11/23, 12/7 and 12/21, identified the home health aide was not providing care according to the care plan, not performing tasks competently and not honoring the patient's rights. See G478 interview On 2/8/21 at 9:10 AM with Administrative Assistant. 4) On 2/8/21 at 12:05 PM, during an interview, the Administrator/Clinical Manager explained the Administrative Assistant reported to her about the missed home health aide visits for Patient #1 by Staff I, Home Health Aide. 5) On 2/8/21 at 3:49 PM, during an interview, Staff I, Home Health Aide, explained the Administrative Assistant called her into the office on 12/22/2020 and told her Patient #1 complained about her not coming to provide home health aide services. She denied falsifying documentation and reported every time she documented she was at the patient's home, she was there. She explained Patient #1 was bed ridden and could not answer the door unless the live-in family member was present. She reported she let people know at the office when she missed a visit due to no one answering the door. She did not notify the nurse. Staff I, Home Health Aide, explained she was told to notify the Administrative Assistant of missed visits and the nurse only if there was a medical issue. She reported her proof that she did the visits was in the visit note, because the patient had to sign the visit note at the end of the visit. She confirmed Patient #1 was cognitively able to say whether or not the home health came to the home and provided cares. 6) On 2/9/11 at 11:38 AM, during a interview, the patient reported he/she and live-in family member were always home when agency scheduled the home health aide to come to the home to provide services, but the home health aide did not show up. The patient denied refusing any services. The patient denied ever signing or initialing a visit note. 7) See G478 interview on 2/9/21 at 1:27 PM with Staff C, LPN. 8) On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, explained she supervised home health aides by asking the Patients if the home health aide is showing up and following the care plan. She reported Staff C, LPN, never notified her of Patient #1's complaints. Staff D, RN, explained Staff C, LPN usually does not notify her, only the Administrative Assistant. She reported the Administrative Assistant did notify her about problems with Staff I, Home Health Aide, and Staff D, RN, spoke with Staff I about concerns just right before Staff I's left employment. 9) On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported Staff I, Home Health Aide, told her she provided home health aide services and she believed her. The Administrative Assistant explained the staff were supposed to have patient's electronically sign the visit note at the end of the visit, but sometimes this did not get done. The Administrative Assistant reviewed the sign in record for home health aide visits for Patient #1 provided by Staff I, Home Health Aide. The signature page for the patient does not print with the visit note, but observation showed the patient's initials, and not a signature with each of the documented visits. The Administrative Assistant reported staff could easily sign the patient's initials for the patient. 10) On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported during the time period the agency scheduled Staff I, Home Health Aide, to provide cares to the patient, the patient's hygiene went downhill. The patient could not shower, and needed assistance with a bed bath. Staff C, LPN, reported the patient was obese and developed rashes in the skin folds. Clinical record review of the skilled nursing visit notes, dated 10/20, 10/22, 10/27, 10/29, 11/3, 11/5, 11/10, 11/12, 11/17, 11/19, 11/24, 11/26, 12/1, 12/3, 12/8, 12/10, 12/15, 12/17 and 12/22/2020, lacked documentation of any skin or hygiene assessment issues. b. The home health aide visit notes, dated 11/25, 11/30, 12/2, 12/4, 12/7, 12/9, 12/11 and 12/14/2020, included documentation the home health aide recorded the patient's last bowel movement, but the visit notes lacked any further documentation which specified when the patient's last bowel movement occurred. c. The clinical record included documentation of 3 missed home health aide visits the week of 12/20/2020, dated 12/21, 12/23 and 12/25/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. On 2/9/21 at 11:38 AM, during an interview, the patient reported he/she did not refuse any services the week of 12/20/2020. The patient reported the agency did not call or offer any services that week. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant explained they had one home health aide staff already on medical leave and then Staff I was no longer employed on 12/22/20. She reported having trouble scheduling home health aide services for Patient #1 and other patients also receiving home health aide services from Staff I. The Administrative Assistant reported the agency was short-staffed and they were unable to meet the needs of the patients. She explained the other home health aides were already "jamming visits" in and were unable to pick up extra visits. On 2/16/21 at 3:20 PM, during an interview, the Administrator/Clinical Manager reported the Administrative Assistant does the scheduling, but she was aware they had staffing issues for home health aide services after Staff I, left employment. The Administrator explained for patients she completed missed visit notes on, "patient/family uncooperative" was just one of the choices and she realizes this was not the right choice for the reason for the missed visit. The clinical record contained incomplete, inaccurate or false documentation. 2. Patient #2 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POC, dated 10/30/2020 to 12/28/2020 and 12/29 to 2/26/2020, included orders for skilled nursing services 1 time per week and home health aide services 2 times per week. b. The clinical record included documentation of 2 missed home health aide visits the week of 12/27/2020, dated 12/28 and 12/31, and 2 missed home health visits the week of 1/3/21, dated 1/4 and 1/7/2020. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. c. The clinical record lacked documentation agency staff notified the patient of the inability to provide home health aide services during the week of 12/27/2020 and 1/3/21. On 2/9/21 at 9:25 AM, during an interview, the patient reported no one called or showed up to provide services the 2 weeks after Christmas. The patient denied refusing services. The clinical record contained inaccurate documentation. 3. Patient #4 had a start of care date of 9/21/2020. Review of the clinical record revealed the following: The POC, dated 11/20/2020 to 1/18/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. The clinical record included documentation of 1 missed home health aide visit the week of 12/20/2020, dated 12/24, and one missed home health aide visit the week of 12/27/2020, dated 12/31. The missed visits notes included the following reason: patient/family uncooperative and included a signature of completion by the Administrator/Clinical Manager. On 2/9/21 at 10:03 AM, during an interview, the patient reported the patient did not refuse home health aide visits the weeks of Christmas and New Years. The patient reported staff were scheduled to come and no one showed. The missed visit notes contained inaccurate information on why the patient did not receive home health aide services. b. The home health aide care plans, dated 11/16/2020, included RN instructions to the home health aide to complete the task of bathing the patient in the tub. On 2/9/21 at 10:03 AM, during an interview, the patient reported he/she never takes a tub bath due to not being able to get in and out of the tub. The patient reported only showering and the home health aides always help with getting the patient in and out of the shower safely. On 2/16/21 at 12:32 PM, during an interview, Staff D, RN, reported she was aware that patient showered and did not take a tub bath, she just accidentally put the wrong bath type on the home health aide care plan. The RN incorrectly identified the bath type on the home health aide care plan. 4. Patient #5 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. The POC, dated 11/9/2020 to 1/7/2021, included physician orders for skilled nursing and home health aide services 1 time per week. b. The home health aide care plan, dated 11/16/2020, included RN instructions to the home health aide to remind the patient to take medications. c. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient was a fall risk, had dyspnea with moderate exertion, activity intolerance, incontinent of urine, oriented to person only, requires prompting under stressful or unfamiliar conditions, confused during day and evening but not constantly, poor balance, weakness, shuffling gait, required set up assistance for grooming, dressing and toilet hygiene and intermittent assistance with showering. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits 1 time per week, dated 11/13, 11/20, 11/27, 12/4, 12/12 and 12/18/2020. On 2/9/21 at 10:56 AM, during an interview, the patient reported Staff I, Home Health Aide, only showed up 1 time and never came back. The patient explained he/she called the office to complain, but the patient was not sure who he/she talked to about the complaint. The patient was not sure when he/she called the office to complain, just some time after the home health aide did not show up. The patient denied telling Staff E, RN, about any concerns with the home health aide. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, reported the patient never complained to her about the home health aide not showing up and the office never told her about any concerns. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported the patient never called the office to complain during the time the Staff I, Home Health Aide was providing services in the home. The Administrative Assistant explained the first time Staff K, Home Health Aide, showed up at the patient's home sometime after Staff I left employment, the patient called into the office with concerns of not knowing what to do with Staff K, Home Health Aide. The patient told her that the patient had never had a home health aide before and did not know what to do with Staff K. The Administrative Assistant reported she did not realize at that time that the patient meant Staff I, Home Health Aide, had not been providing services. The clinical record contained inaccurate or false documentation. 5. Patient #7 had a start of care date of 9/28/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/28/2020 to 11/26/2020 and 11/27/2020 to 1/25/2020, included orders for skilled nursing and home health aide services. 1) The home health aide care plans, dated 9/30, 11/23 and 11/27/2020, included RN instructions to the home health aide to complete the task of recording the patient's last bowel movement. 2) The home health aide visit notes, dated 11/28, 12/1, 12/5, 12/8, 12/11, 12/15 and 12/17/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. b. The Home Health Aide Supervisory visit notes, dated 10/13, 10/26 and 11/19/2020, included documentation Staff G, RN, supervised Staff L, Home Health Aide, and documented the home health aide had followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. The clinical record lacked documentation Staff L had provided any home health aide services in the home. c. The Home Health Aide Supervisory visit notes, dated 12/1 and 12/15/2020, included documentation Staff C, LPN, supervised Staff M, Home Health Aide, and included documentation the home health aide had followed the care plan, provided visits and as scheduled, was competent with tasks and honored the patient's rights. The clinical record lacked documentation Staff M had provided any home health aide services in the home. The clinical record contained incomplete and inaccurate documentation. 6. Patient #8 had a start of care date of 8/27/2020. Review of the clinical record revealed the following: The POC, dated 8/27/2020 to 10/25/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week. The POC, dated 10/26/2020 to 12/24/2020, included orders for skilled nursing services weekly and home health aide services 2 times per week for 5 weeks, 1 time per week for 1 week, and no home health aide services the last 3 weeks of the certification period. The home health aide care plans, dated 8/28 and 10/23/2020, included RN instructions to the home health aide to complete the following tasks: shower, assist with dressing, lotion, comb hair, shampoo hair, oral care, assist to toilet, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. a. The clinical record included documentation of completed and missed home health aide visits by Staff I, Home Health Aide, dated 10/14 to 11/30/2020. Staff I, Home Health Aide, documented providing home health aide visits, dated 10/14, 10/19, 10/21, 11/2, 11/9, 11/11, 11/16, 11/18, 11/23, 11/25 and 11/30/2020 (see G0800 for tasks completed), and she documented missed visits, dated 10/16 (due to only seeing patient on Mondays), 10/26, 10/28 and 11/4/2020. See G478 interview on 2/9/21 at 1:40 PM, during an interview, the patient reported Staff I, Home Health Aide, only showed up 2 times between October and the end of November 2020. The patient reported the 2 times Staff I, Home Health Aide, did show up, she only sat on the patient's couch and did not do anything. The patient explained after the first time the home health aide did not do anything, the patient told Staff D, RN. The patient reported telling Staff D, RN, again after Staff I, Home Health Aide, showed up the second time and did not do anything. The patient was not sure on the dates, but reported the patient knew he/she had told Staff D, RN, sometime prior to stopping home health aide services. 2) Review of the clinical record identified an interim physician order, dated 12/2/2020, included orders to discontinue home health aide services per the patient's request. G478 interview on 2/16/21 at 12:32 PM, during an interview, Staff D, RN, reported she remembered the patient complaining Staff I, Home Health Aide, was not showing up and asked to discontinue services. 4) Review of the clinical record identified Home Health Aide Supervisory visit notes, dated 10/28, 11/11, 11/25 and 12/2/2020, included documentation Staff D, RN, completed the note and documented the home health aide followed the patient's care plan, arrived for visits as scheduled, maintains open communication with the patient and honored the patient's rights. b. The home health aide care plan, dated 10/23/2020, identified the patient received occupational and physical therapy services. The clinical record lacked documentation the patient received those services at that time. c. A home health aide visit note, dated 11/30/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. The clinical record contained inaccurate, incomplete and/or false information. 7. Patient #9 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. A patient signed consent form for care and services, signed by the patient and agency staff on 11/9/2020, identified the agency planned to provide skilled nursing, home health aide and physical therapy services. b. The POC, dated 11/9/2020 to 1/7/2021, identified a diagnosis of fracture of the first lumbar vertebra and included orders for skilled nursing 1 time per week, home health aide services 2 times per week and physical therapy services 1 time the first week and then 2 times for 3 weeks. c. The comprehensive assessment completed at the start of care, dated 11/9/2020, identified the patient suffered from lower back pain with an intensity of 3 to 10 (with 10 the worst) all the time, occasional incontinence, at risk for falls, oriented to person and place, forgetful, but lacked a memory deficit, confused in new or complex situations, required assistance with set up for grooming and upper body dressing, dependent on assistance for lower body dressing, unable to shower without assistance, unable to maintain toilet hygiene and transfer without assistance and chairfast, but able to wheel self independently. d. The home health aide care plan, dated 11/10/2020, included RN instructions to the home health aide to complete the following tasks: chair bath, tub bath, shower with chair, assist with dressing, lotion, shampoo hair, assist to toilet and incontinence care. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 11/19 through 12/16/2020. f. The home health aide visit notes, dated 11/19, 11/23, 11/25, 11/30, 12/3, 12/7, 12/10 (documented on two different days and 2 different notes for the same day) and 12/16/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks or a reason why the aide failed to complete the assigned tasks. g. On 2/10/21 at 2:09 PM, during an interview, the patient reported she had not wanted home health aide or homemaker services. She reported she had been able to meet her own needs including showering independently. The patient told the nurse Staff H, RN, the patient did not want anyone else coming into the home. The patient denied receiving services from any agency staff person with the exception of Staff H, RN. On 2/16/21 at 12:17 PM, during an interview, Staff H, RN, reported the patient was confusing. The patient agreed to home health aide services at first due to lower back pain and safety concerns, but refused visits after the first 1 to 2 times. Staff H, RN, reported the patient agreed to accept the service when asked again. Staff H, RN, was not sure if the patient had let anyone provide home health aide services. Staff H, RN, reported she supervises the home health aides by asking the patient if the home health aide is following the care plan, reviews the tasks on the care plan with the patient to ensure the home health aide is following the plan, ask if the patient is satisfied, and, on occasion if the home health aide is new, review the home health aide's documentation. The clinical record contained inaccurate and/or false documentation. 8. Patient #10 had a start of care date of 7/21/2020. Review of the clinical record revealed the following: The POCs, dated 9/19/2020 to 11/17/2020 and 11/18/2020 to 1/16/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. a. The home health aide care plans, dated 9/19 and 11/18/2020, included RN instruction to the home health aide to complete the task of recording the patient's last bowel movement. The home health aide visit notes, dated 11/24, 11/27, 12/10 and 12/17/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. b. The home health aide care plans, dated 9/19 and 11/18/2020, identified the patient received occupational and physical therapy services. The POCs and clinical record lacked documentation the patient received those services at that time. The clinical record contained inaccurate or incomplete information. 9. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: a. The POC, dated 10/9/2020 to 12/7/2020, included orders for home health aide services 2 times per week and skilled nursing services weekly. b. The home health aide care plan, dated 10/6, included RN instructions to the home health aide to complete the task of recording the patient's last bowel movement. c. The home health aide visit note, dated 11/24/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. 10. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The POC, dated 8/31/2020 to 10/29/2020, included physician orders for skilled nursing one time per week and home health aide services 2 times per week. 1) An interim physician order, dated 9/21/2020, included an order to increase home health aide services to 3 times per week. 2) The POC, dated 10/30/2020 to 12/28/2020, included an order for home health aide services 1 time the first week and then 2 times per week. 3) The home health aide care plans, dated 9/8 and 10/29/2020, included RN instructions to the home health aide to complete the following tasks: tub bath, assist with dressing, lotion and remind the patient to take medications. 4) The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9 to 11/27/2020. 5) The home health aide visit notes, dated 10/9, 10/12, 10/14, 10/19, 10/21, 10/23, 10/26, 10/30 and 11/16/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed any of the assigned personal care tasks (tub bath, assist with dressing, lotion and remind the patient to take medications), or a reason why the home health aide failed to complete the assigned tasks. 6) The home health aide visit notes, dated 10/16, 10/28, 11/2, 11/4, 11/9, 11/11,11/23, 11/25 and 11/27/2020, included documentation the home health aide completed the task of reminding the patient to take medication, but lacked documentation the home health aide completed the other assigned tasks. 7) The Home Health Aide Supervisory visit notes, dated 10/30, 11/13, 11/27 and 12/11/2020, included documentation Staff C, LPN, had supervised the home health aide and documented the home health aide followed the care plan, arrived for visits as scheduled, demonstrated competency and honored patient rights. On 2/10/21 at 12:48 PM, during an interview, the patient reported he/she had not refused or canceled any services the end of November through 12/9/2020. The patient reported Staff I, Home Health Aide, would come to the patient's home, do one task and then get on her phone. The patient reported Staff I, Home Health Aide, never offered to assist the patient with bathing, dressing or applying lotion, and she never reminded the patient to take medications. The patient reported the patient told Staff I, Home Health Aide, to not come back after 4 weeks due to mishandling and haphazardly storing some glass Halloween decorations and almost ruining the patient's carpet. The patient reported the patient called the agency and complained about Staff I, Home Health Aide. On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported the patient had complained to her about Staff I, Home Health Aide, not doing assigned tasks. b. A Home Health Aide Supervisory visit note, dated 10/30/2020, included documentation Staff C, LPN, had supervised Staff P, Home Health Aide, and documented the home health aide followed the care plan, arrived for visits as scheduled, demonstrated competency and honored patient rights. The clinical record lacked documentation Staff P, Home Health Aide, had provided services in the patient's home. The clinical record contained inaccurate or false documentation. 11. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: a. The POCs, dated 10/23/2020 to 12/21/2020 and 12/22/2020 to 2/19/2021, included orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The updates to the comprehensive assessment completed at the time of recertification, dated 10/20 and 12/21/2020, identified the patient was at risk for falls, activity intolerance, poor balance, muscle weakness, unsteady gait, difficulty breathing with moderate exertion, bladder incontinence, oriented to person and place, forgetful, required set up assistance with grooming, dressing and toilet hygiene and intermittent assistance with bathing. c. The home health aide care plans, dated 8/24, 10/21 and 12/21/2020, included RN instructions to the home health aide to complete the following task: record the patient's last bowel movement. d. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/12 to 12/11/2020. e. The clinical record included documentation Staff J, Home Health Aide, provided home health aide visits, dated 12/14 to 12/28/2020. f. The home health aide visits, dated 10/12, 10/16, 10/19, 10/23, 10/26, 11/2, 11/6, 11/9, 11/13, 11/16, 11/20, 11/23 and 12/11/2020, included documentation the home health aide completed homemaker tasks, but lacked documentation the home health aide completed the assigned personal care task. g. The home health aide visit, dated 12/7/2020, included documentation of a signature of completion, but lacked documentation of the completion of any tasks, or a reason why the home health aide failed to do any tasks. h. The home health aide visits, dated 12/14, 12/21 and 12/28/2020, included documentation the patient refused to tell the home health aide when the patient's last bowel movement occurred, and the home health aide documented the completion of only homemaker tasks. g. The Home Health Aide Supervisory visit note, dated 10/30/2020, completed by Staff Q, LPN, included documentation she had supervised the home health aide and documented the home health aide was not maintaining open communication, not arriving for visits as scheduled, not following the care plan and not demonstrating competency in completing tasks. Staff Q documented this as an issue with how the patient wanted the house cleaned. h. The Home Health Aide Supervisory visit notes, dated 11/10, 12/8 and 12/21/2020, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication, arrived for visits as scheduled, followed the care plan and completed tasks competently. On 2/10/21 at 3:15 PM, during an interview, the patient reported he/she remembered Staff I, Home Health Aide. The patient did not write down dates, but reported Staff I, Home Health Aide, came on Mondays and Fridays the times she did show up. The patient reported Staff I, Home Health Aide, never asked the patient about the patient's bowel movements. The patient reported none of the current staff have ever done this either. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, reported the patient had complained to her several times about Staff I, Home Health Aide, not showing up. Staff E, RN, reported the patient was cognitive and able to state the home health aide had not been coming to provide services. The clinical record incomplete, inaccurate and/or false information. 12. Patient #15 had a start of care date of 9/17/2020. Review of the clinical record revealed the following: The POC, dated 11/16/2020 to 1/14/2021, included physician orders for skilled nursing and home health aide services 2 times per week. a. The home health aide care plan, dated 11/16/2020, identified the patient received physical and occupational therapy. The POC lacked orders for physical and occupational therapy services. The nurse failed to updated the home health aide care plan to accurately reflect services the agency provided to the patient. b. The home health aide care plan, dated 11/16/2020, included RN instructions to the home health aide to complete the task of recording the patient's last bowel movement. The home health aide visit notes, dated 12/1, 12/4, 12/8, 12/11, 12/15 and 12/18/2020 and 1/8/21, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. c. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/9 to 12/18/2020. The clinical record included documentation the Administrator/Clinical Manager completed 2 missed home health aide visit notes the week of 12/20/2020, dated 12/22 and 12/25, due to the patient being uncooperative, and 2 missed home health aide visit notes the week of 12/27/2020, dated 12/29/2020 (no reason given) and 1/1/21. The Administrator/Clinical Manager documented the patient was uncooperative for a visit on 1/1/21. On 2/10/21 at 3:45 PM, during an interview, the patient reported he/she did not refuse home health aide services the weeks of Christmas (12/20/2020) and New Year's (12/27/2020), and the patient did not know why he/she did not get services those weeks. The clinical record contained inaccurate or incomplete documentation. 13. Patient #16 had a start of care date of 2/10/2020. Review of the clinical record revealed the following: a. The POC, dated 12/2/2020 to 1/30/2021, included physician orders for skilled nursing and home health aide services 2 times per week. The clinical record included documentation Staff I, former Home Health Aide, provided home health aide visits, dated 12/4 to 12/21/2020. On 2/11/21 at 10:21 AM, during an interview, the patient reported Staff I, Home Health Aide, would say she was going to show up and then would not come. The patient clarified Staff I, Home Health Aide, did show up some of the times. The patient complained Staff I, Home Health Aide, would not do a good job when she did show up. The patient reported he/she complained to the office staff and requested a new home health aide some time around Christmas, but the patient was not sure of the exact date. b. The home health aide care plan, dated 12/1/2020, included RN instructions to the home health aide to complete the task of recording the patient's last bowel movement. The home health aide visit notes, dated 12/16 and 12/21/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. c. The Home Health Aide Supervisory visit note, dated 12/29/2020, completed by Staff C, LPN, documented she supervised Staff J, Home Health Aide, and Staff J maintained open communication with the patient, followed the care plan, arrived for the assigned visits as scheduled, competently completed assigned tasks and honored patient rights. The clinical record lacked documentation Staff J, Home Health Aide, provided home health services to the patient. The clinical record contained incomplete, inaccurate and/or false documentation. 14. Patient #17 had a start of care date of 11/30/2020 and transferred from agency services on 1/14/21. Review of the clinical record revealed the following: The POC, dated 11/30/2020 to 1/28/2021, included orders for skilled nursing services 2 times the first week and then 1 time per week for 8 weeks, home health aide services 2 times per week and occupational therapy 1 time the first week. a. The POC also included the following order: physical therapy (PT) to assess functional status, home environment to eliminate structural barriers, improve safety and functional independence. PT to assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/coordination and transfers. PT to establish home exercise program and plan of care as approved by physician. The POC lacked a scope and frequency for PT services. 1) The clinical record lacked documentation the patient received PT services. On 2/22/21 at 1:15 PM, during an interview, the Administrative Assistant reported it was a mistake on the POC, and the patient was never supposed to receive PT services. 2) The home health aide care plan, dated 11/30/2020, incorrectly identified the patient received PT services. b. The home health aide care plan, dated 11/30/2020, included RN instructions to the home health aide to complete the task of recording the patient's last bowel movement. The home health aide visit notes, dated 12/7, 12/10 and 12/23/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. The clinical record contained incomplete or inaccurate documentation. 15. Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: a. The POCs, dated 10/16/2020 to 12/14/2020 and 12/15/2020 to 2/12/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. b. The home health aide care plans, dated 10/14 and 12/14/2020, identified the patient received physical and occupational therapy. The POC lacked orders for physical and occupational therapy services. The home health aide care plans inaccurately included services the agency was not providing to the patient. 16. Patient #20 had a start of care date of 10/16/2020 and discharged from agency services on 12/7/2020. Review of the clinical record revealed the following: The POC, dated 10/16/2020 to 12/14/2020, identified diagnoses of urinary tract infection and dementia with behavioral disturbance and included physician orders for home health aide services 2 times per week and skilled nursing services 1 time the first week, 2 times per week for 2 weeks and 1 time per week for 6 weeks. The home health aide care plan, dated 10/16/2020, included RN instructions to the home health aide to complete the following personal care tasks: shower with chair, assist with dressing, lotion, comb hair, shampoo hair, oral care, clean dentures, assist to toilet, incontinence care, record last bowel movement, meal set up, encourage fluids, assist with ambulation, assist with transfer, remind to take medications every visit and clean/file nails and shave weekly. a. The clinical record included documentation Staff I, Home Health Aide, provided home health aide visits, dated 10/20, 10/22, 10/27, 10/29, 11/3, 11/5, 11/9, 11/12, 11/17, 11/19, 11/24, 12/1 and 12/5/2020. 1) The home health aide visit note, dated 10/20/2020, included documentation of a signature of completion, dated 10/20/2020. 2) The home health aide visit note, dated 10/22/2020, included documentation of a signature of completion, dated 10/23/2020. 3) The home health aide visit note, dated 10/27/2020, included documentation of a signature of completion, dated 10/26/2020 (signed 1 day prior to the visit). 4) The Home Health Aide Supervisory visit notes, dated 10/29, 11/12 and 11/26/2020, included documentation Staff C, LPN, supervised the home health aide and documented the home health aide maintained open communication with the patient, family, caregiver, representative, arrived for assigned visits as scheduled, followed the patient's care plan and demonstrated competency with assigned tasks. 5) On 2/11/21 at 11:29 AM, during an interview, a family member/caregiver reported not being the patient's primary caregiver, but frequently stayed with the patient during the day. The family member/caregiver explained the patient could not be left alone. The family member/caregiver reported problems with miscommunication with agency staff, no coordination of care delivery and missed home health aide visits. 6) On 2/11/21 at 2:08 PM, during an interview, the patient's representative/family member, reported having documentation in a communication book the family made of Staff I, Home Health Aide, showing up only 3 times, dated 10/20, 10/23 and 10/26/2020, and then not showing back up. The patient's representative/family member reported Staff C, LPN, never asked how home health aide services were going. 7) On 2/16/21 at 12:03 PM, during an interview, Staff G, RN, reported she supervises home health aides either during a routine skilled nursing visit or during the update to the comprehensive assessment at the time of recertification. She explained sometimes the home health aide is present and she will ask the patient about concerns. She will check home health aide documentation at times, but usually the Administrator reviews the documentation. Staff G, RN, explained she went out on 12/7/2020 to do a "Recert" (update to the comprehensive assessment at the time of recertification), but ended up doing a discharge. She reported the family complained Staff I, Home Health Aide, had not been showing up to provide services at that time. Staff G, RN, explained Staff C, LPN, was the patient's primary nurse, so she passed the complaint onto Staff C, LPN, and the Administrative Assistant. 8) On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported she never received any complaints about Staff I, Home Health Aide. When asked how she supervised the home health aide, she reported she asked the patient or another family member. b. The home health aide visit notes, dated 11/24, 12/1 and 12/5/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. The clinical record contained false, inaccurate and incomplete documentation. 17. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The POC, dated 10/13/2020 to 12/11/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. b. The POC, dated 12/12/2020 to 2/9/2021, included physician orders for skilled nursing 1 time per week and home health aide services 2 times per week. c. The update to the comprehensive assessment completed at the time of recertification, dated 12/9/2020, identified the patient had diabetes, high blood pressure, heart failure, was a fall risk, absence of a capable caregiver, difficulty breathing with minimal exertion, oriented to person and place, forgetful, poor balance, muscle weakness, required set up assistance for grooming and dressing and intermittent assistance for bathing. d. The home health aide care plans, dated 10/13 and 12/9/2020, included RN instructions to the home health aide to complete the following personal care tasks: remind the patient to take medications. e. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services 10/20 to 12/21/2020. f. The home health aide visit note, dated 10/23/2020, included documentation Staff I, Home Health Aide, completed homemaker tasks, but lacked documentation or a reason why the home health aide failed to complete the assigned personal care task of reminding the patient to take medications. g. The home health aide visit notes, dated 10/20, 10/30, 11/3, 11/6, 11/9, 11/11, 11/13, 11/18, 11/20, 11/23, 11/30, 12/2, 12/7, 12/9, 12/14, 12/18 and 12/21/2020, included documentation Staff I, Home Health Aide, completed the assigned personal task of reminding the patient to take medications. h. The Home Health Aide Supervisory visit notes, dated 11/11, 11/25, 12/9 and 12/23, included documentation Staff E, RN, supervised the home health aide and documented the home health aide maintained open communication with the patient, arrived for assigned visits as scheduled, followed the care plan and demonstrated competency in assigned tasks. On 2/16/21 at 11:15 AM, during an interview, the patient reported Staff I, Home Health Aide, only sat on the patient's couch and visited with the patient when she came. The patient reported Staff I, Home Health Aide, only showed up 2 times when she actually came into the patient's home. When she did come, she told the patient she was too busy to do any of the tasks. The patient reported there were a few times when Staff I, Home Health Aide, came to the door and told the patient she could not do services that day. The patient reported the patient complained about Staff I, Home Health Aide, to Staff E, RN, "all the time" and also called the agency's office to complain throughout the time Staff I, Home Health Aide, was supposed to be providing services. The patient reported Staff I, Home Health Aide, never reminded the patient to take medications. On 2/16/21 at 12:56 PM, during an interview, Staff E, RN, confirmed the patient was accurate and the patient had complained to her several times about Staff I, Home Health Aide. Staff E, RN, reported the patient would wait for Staff I, Home Health Aide, to show for scheduled visits and Staff I would never show up. Staff E, RN, reported she spoke with the Administrative Assistant about the patient's concerns, and the Administrative Assistant told Staff E, RN, she had other complaints about Staff I, Home Health Aide, and she would talk with Staff I. Staff E, RN, reported she followed up again with the Administrative Assistant, because the patient continued to complain. On 2/16/21 at 3:00 PM, during an interview, the Administrative Assistant reported she knew the patient had been frustrated. She reported it had been hard to schedule the home health aide with the patient due to the patient's sleep schedule. The clinical record contained false documentation. 18. Patient #25 had a start of care date of 8/26/2020 and transferred from agency services on 1/20/21. Review of the clinical record revealed the following: The POC, dated 10/25/2020 to 12/23/2020, included physician orders for skilled nursing and home health aide services 1 time per week. The POC included orders for the home health aide to provide assistance with personal cares and activities of daily living as indicated by limitations on the patient's functional and physical status impeding self-care. The home health aide care plan (titled homemaker care plan in the electronic system), dated 10/21/2020, included RN instructions to the home health aide to complete the following personal care tasks: record the patient's last bowel movement, meal set up, limit fluids, assist with ambulation, assist with transfer and remind the patient to take medications. a. The clinical record included documentation Staff I, Home Health Aide, provided home health aide services, dated 11/5, 11/12, 11/19, 11/25 and 12/3/2020. 1) The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion by Staff C, LPN, dated 12/11/2020. Staff C, LPN, documented she supervised Staff I, Home Health Aide, and Staff I failed to maintain open communication with the patient, failed to arrive for assigned visits as scheduled, failed to follow the care plan for completion of assigned tasks, failed to competently complete assigned tasks and failed to honor patient rights. 2) On 2/16/21 at 2:25 PM, during an interview, Staff C, LPN, reported the patient told her that Staff I, Home Health Aide, had not been coming to provide home health aide services. Staff C, LPN, reported the patient complained prior to 12/17/2020, but she was unsure of dates. Staff C, LPN, reported the patient was unable to personal cares independently. The clinical record contained false documentation. b. The home health aide visit note, dated 12/3/2020, included documentation the home health aide completed the task of recording the patient's last bowel movement, but failed to document when the bowel movement occurred. The clinical record contained incomplete information. The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.

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 patient clinical record review and agency policy review, the agency failed to ensure agency staff properly authenticated all clinical entry notes for 18 of 24 sampled patients (Patients #1, #2, #4, #5, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #23 and #25) receiving home home health services. The agency reported 98 out of 150 patients received home health aide services at the time of the survey. Failure to ensure all clinical record documentation was dated, timed and signed with staff title, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: Review of the agency's undated policy, titled Medical Record Content, identified the medical record will contain the name of the staff providing care and the date agency provided the care. 1. Patient #1 had a start of care date of 3/5/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 10/26/2020, included documentation of a signature of completion, dated 10/24/2020 (signed 2 days prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 11/23/2020, included documentation of a signature of completion, dated 11/20/2020 (signed 3 days prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 12/7/2020, included documentation of a signature of completion, dated 12/5/2020 (signed 2 days prior to the actual visit). Agency staff signed their authentication of the notes prior to the actual date the visit occurred. 2. Patient #2 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 12/3/2020, included documentation of a signature of completion, dated 12/1/2020 (signed 2 days prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion, dated 12/14/2020 (signed 3 days prior to the actual visit). Agency staff signed their authentication of the notes prior to the actual date the visit occurred. 3. Patient #4 had a start of care date of 9/21/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 11/11/2020, included documentation of a signature of completion, dated 11/10/2020 (signed 1 day prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/15/2020, included documentation of a signature of completion, dated 12/1/2020 (signed 14 days prior to the actual visit). 4. Patient #5 had a start of care date of 11/9/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 11/20/2020, included documentation of a signature of completion, dated 11/19/2020 (signed 1 day prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/4/2020, included documentation of a signature of completion, dated 12/1/2020 (signed 3 days prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 12/18/2020, included documentation of a signature of completion, dated 12/14/2020 (signed 4 days prior to the actual visit). 5. Patient #7 had a start of care date of 9/28/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 10/27/2020, included documentation of a signature of completion, dated 10/26/2020 (signed 1 day prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 11/10/2020, included documentation of a signature of completion, dated 11/9/2020 (signed 1 day prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 11/24/2020, included documentation of a signature of completion, dated 11/20/2020 (signed 4 days prior to the actual visit). d. The Home Health Aide Supervisory visit note, dated 12/15/2020, included documentation of a signature of completion, dated 12/9/2020 (signed 6 days prior to the actual visit). 6. Patient #10 had a start of care date of 7/21/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 10/19/2020, included documentation of a signature of completion, dated 10/12/2020 (signed 7 days prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 11/2/2020, included documentation of a signature of completion, dated 10/30/2020 (signed 3 days prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 11/16/2020, included documentation of a signature of completion, dated 11/15/2020 (signed 1 day prior to the actual visit). d. The Home Health Aide Supervisory visit note, dated 12/3/2020, included documentation of a signature of completion, dated 12/1/2020 (signed 2 days prior to the actual visit). e. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion, dated 12/11/2020 (signed 6 days prior to the actual visit). f. The Home Health Aide Supervisory visit note, dated 12/31/2020, included documentation of a signature of completion, dated 12/25/2020 (signed 6 days prior to the actual visit). 7. Patient #11 had a start of care date of 8/10/2020. Review of the clinical record revealed the following: The Home Health Aide Supervisory visit note, dated 12/21/2020, included documentation of a signature of completion, dated 12/20/2020 (signed 1 day prior to the actual visit). 8. Patient #12 had a start of care date of 11/18/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 12/14/2020, included documentation of a signature of completion, dated 12/11/2020 (signed 3 days prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/28/2020, included documentation of a signature of completion, dated 12/24/2020 (signed 4 days prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 1/11/21, included documentation of a signature of completion, dated 1/8/21 (signed 3 days prior to the actual visit). 9. Patient #13 had a start of care date of 8/31/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 11/13/2020, included documentation of a signature of completion, dated 11/9/2020 (signed 4 days prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 11/27/2020, included documentation of a signature of completion, dated 11/20/2020 (signed 7 days prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 12/11/2020, included documentation of a signature of completion, dated 12/5/2020 (signed 6 days prior to the actual visit). 10. Patient #14 had a start of care date of 8/24/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 11/10/2020, included documentation of a signature of completion, dated 11/9/2020 (signed 1 day prior to the actual visit). b. A home health aide visit note, dated 12/28/2020, included documentation of tasks the home health aide completed or the patient refused, but lacked documentation of a signature, title and date of completion. 11. Patient #15 had a start of care date of 9/17/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 11/10/2020, included documentation of a signature of completion, dated 11/9/2020 (signed 1 day prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/22/2020, included documentation of a signature of completion, dated 12/20/2020 (signed 2 days prior to the actual visit). 12. Patient #16 had a start of care date of 2/10/2020. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 10/20/2020, included documentation of a signature of completion, dated 10/17/2020 (signed 3 days prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/15/2020, included documentation of a signature of completion, dated 12/11/2020 (signed 4 days prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 12/29/2020, included documentation of a signature of completion, dated 12/25/2020 (signed 4 days prior to the actual visit). 13. Patient #17 had a start of care date of 11/30/2020 and transferred from agency services on 1/14/21. Review of the clinical record revealed the following: The Home Health Aide Supervisory visit note, dated 12/9/2020, included documentation of a signature of completion, dated 12/8/2020 (signed 1 day prior to the actual visit). 14. Patient #18 had a start of care date of 8/17/2020 and discharged from agency services on 1/4/21. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 10/20/2020, included documentation of a signature of completion, dated 10/17/2020 (signed 3 days prior to the actual visit). b. A home health aide visit note, dated 10/28/2020, included documentation of a signature of completion, dated 10/27/2020 (signed one day prior to the actual visit). c. A home health aide visit note, dated 10/30/2020, included documentation of a signature of completion, dated 10/29/2020 (signed one day prior to the actual visit). d. The Home Health Aide Supervisory visit note, dated 11/3/2020, included documentation of a signature of completion, dated 10/30/2020 (signed 4 days prior to the actual visit). e. A home health aide visit note, dated 11/4/2020, included documentation of a signature of completion, dated 11/3/2020 (signed one day prior to the actual visit). 15. Patient #19 had a start of care dare of 10/8/2020 and transferred from agency services on 10/27/2020. Review of the clinical record revealed the following: The Home Health Aide Supervisory visit note, dated 10/21/2020, included documentation of a signature of completion, dated 10/20/2020 (signed 1 day prior to the actual visit). 16. Patient #20 had a start of care date of 10/16/2020 and discharged from agency services on 12/7/2020. Review of the clinical record revealed the following: a. A home health aide visit note, dated 10/27/2020, included documentation of a signature of completion, dated 10/26/2020 (signed one day prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 10/29/2020, included documentation of a signature of completion, dated 10/24/2020 (signed 5 days prior to the actual visit). c. A home health aide visit note, dated 11/3/2020, included documentation of a signature of completion, dated 11/2/2020 (signed one day prior to the actual visit). d. The Home Health Aide Supervisory visit note, dated 11/12/2020, included documentation of a signature of completion, dated 11/9/2020 (signed 3 days prior to the actual visit). e. A home health aide visit note, dated 11/17/2020, included documentation of a signature of completion, dated 11/16/2020 (signed one day prior to the actual visit). f. The Home Health Aide Supervisory visit note, dated 11/26/2020, included documentation of a signature of completion, dated 11/20/2020 (signed 6 days prior to the actual visit). 17. Patient #23 had a start of care date of 10/13/2020 and transferred from agency services on 2/5/21. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 11/25/2020, included documentation of a signature of completion, dated 11/24/2020 (signed 1 day prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/23/2020, included documentation of a signature of completion, dated 12/20/2020 (signed 3 days prior to the actual visit). 18. Patient #25 had a start of care date of 8/26/2020 and transferred from agency services on 1/20/21. Review of the clinical record revealed the following: a. The Home Health Aide Supervisory visit note, dated 11/19/2020, included documentation of a signature of completion, dated 11/15/2020 (signed 4 days prior to the actual visit). b. The Home Health Aide Supervisory visit note, dated 12/3/2020, included documentation of a signature of completion, dated 12/1/2020 (signed 2 days prior to the actual visit). c. The Home Health Aide Supervisory visit note, dated 12/17/2020, included documentation of a signature of completion, dated 12/11/2020 (signed 6 days prior to the actual visit). The Administrator/Clinical Manager and Administrative Assistant received the above findings and agency staff provided no further information prior to the end of the survey.