Every finding on record at Nurse Care Health Group LLC

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 36459 Health Facilities Evaluator Nurse, Surveyor ID: 44802 Unduplicated Admissions: 13 Active Patients: 10 Sample Size: 7 Home Visits: 3

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to maintain a current medication profile for three of seven patients (Patient 1, 2, and 4). This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. c. A review of Patient 4's Patient Profile indicated a Start of Care (SOC) on 11/28/2023, with primary diagnosis of Hydrocephalus (a condition in which fluid accumulates in the brain, typically in young children, enlarging the head and sometimes causing brain damage). A review of Patient 4 's Plan of Care (POC) for certification period 03/28/2023 to 5/26/2023, included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 140 hours per month to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. A review of Patient 4’s Medication Profile indicated an order for Oxygen, nasal cannula 0.5 liter/minute when sleeping. On 5/16/2023 at 10:00 am, a home visit was conducted with the LVN at Patient 4’s residence. Patient 4 was alert and was sitting on a baby highchair in the dining room. Patient Caregiver (CG 1) was present during the home visit. Patient 4 had an NG tube to the left nostril and taped to left cheek. LVN 1 stated that Patient 1 is given 120 mL of Kate Farms (KD) Pediatric Standard, Vanilla, 1.2 calorie/mL by mouth and the remaining amount that Patient 4 cannot finish is administered an NG tube feeding with via feeding pump at 150 ml/hour. The LVN stated that Patient 4 did not finish 70 mL of the 120 mL KD and administered it with the feeding pump. During the medication review, CG 1 stated that the oxygen prescribed to Patient 4 was discontinued in January 2023. During an interview on 5/17/2023 at 2:00 pm, the Director of Patient Care Services (DPCS) stated that the patient’s medication profile should be updated immediately so there is no error in medication administration. The DPCS stated that it is important that the nurse and caregiver know not to give the patient medication that is not ordered. A review of the HHA’s (undated) policy, Medication Profile, indicated that a patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The policy indicated that medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. a. A review of Patient 1's Patient Profile indicated a Start of Care (SOC) date of 09/04/2014, with primary diagnosis of anemias (not enough healthy red blood cells) due to enzyme disorder (inherited defects that results in a number of life changing or life threatening conditions). A review of Patient 1 's Plan of Care (POC) for certification period 03/26/2023 to 5/24/2023, indicated an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) 24 hours per day. On 05/16/2023, at 5:00 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 4) was conducted at Patient 1’s residence. A review of Patient 1’s Medication Profile provided by the agency, indicated that patient had an order for Budesonide inhalation solution (used to prevent difficulty breathing, chest tightness, wheezing and cough caused by asthma) 0.5 milligrams (mg – unit of measurement) per two milliliters (ml - unit if measurement), Ipratropium (used to prevent wheexing, shortness of breath, cough and chest tightmess) 200 micrograms (mcg – unit of measurement) per 2.5 ml and Oxycodone (used to relieve moderate to severe pain) 5 mg per 5 ml. A review of Patient 1’s current medication indicated the patient takes Budesonide inhalation solution 0.5 ml per 2 ml two times per day and patient no longer takes Ipratropium 22 mcg per 2.5 ml and Oxycodone 5mg per 5 ml. During an interview with Patient 1’s Caregiver (CG 2) on 05/16/2023, at 5:32 p.m., she stated that patient no longer takes Ipratropium and Oxycodone. b. A review of Patient 3's Patient Profile indicated a Start of Care (SOC) date of 06/15/2022, with primary diagnosis of microcephaly ( a congenital condition associated with incomplete brain development). A review of Patient 3 's Plan of Care (POC) for certification period 04/11/2023 to 6/09/2023, indicated an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 330 hours per month. On 05/16/2023, at 11:30 a.m., a joint home visit with the Licensed Vocational Nurse (LVN 3) was conducted at Patient 3’s residence. A review of Patient 3’s Medication Profile provided by the agency, indicated that patient had an order for Simethicone (used to relieve too much gas in the stomach) 40 mg per 0.6 ml, Clonidine HCL (used to treat high blood pressure) 0.2 mg and Flonase (used to relieve nasal congestion, sneezing, runny nose and itchy or watery eyes due to allergy symptoms) nasal spray. A review of Patient 3’s current medication indicated the patient takes Clonidine HCL 0.1 mg and patient no longer takes Simethicone 40 mg per 0.6 ml and Flonase nasal spray and instead takes Azelastine HCL (used to treat allergy symptoms such as sneezing, itching or runny nose) nasal solution 0.1 percent. During an interview with Patient 3’s Caregiver (CG 3) on 05/16/2023, at 12:320 p.m., she stated that patient no longer takes Simethicone and Flonase has been replaced with Azelastine.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to follow the plan of care and to perform a complete skilled nurse assessment for five of seven patients (Patients 1, 2, 3, 4, and 5). This deficient practice placed the patient at a potential risk for serious complication which could affect the overall health status and well-being of the patient. d. A review of Patient 4's Patient Profile indicated a Start of Care (SOC) on 11/28/2023, with primary diagnosis of Hydrocephalus (a condition in which fluid accumulates in the brain, typically in young children, enlarging the head and sometimes causing brain damage). A review of Patient 4 's Plan of Care (POC) for certification period 03/28/2023 to 5/26/2023, included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 140 hours per month to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. The POC indicated to administer nasogastric (NG, reaching or supplying the stomach via the nose) as order, nourish breastmilk/Enfamil (milk-based, iron-fortified, routine infant meal) formula 150 milliliters/hours, six feedings a day. The POC indicated to check the NG tube for residual before feeding and as necessary and if residual greater than 30 mL to hold feedings for 30 minutes then recheck. If residual is still greater than 60 mL, hold feeding and call physician and notify patient caregiver (PCG). The POC indicated to flush NG tube with 15-60 mL water before and after medication and feedings as needed. The POC indicated for aspiration precautions at all times. A review of Patient 4’s Skilled Nurse Flow Sheet, dated 5/01/2023 did not have pulse, respiration rate or oxygen saturation documented. The residual check box was blank, the flushes solution was water with amount 1 milliliter (mL) with feedings and medications. The intake record indicated one feeding at 10 am with 2 mL water flush. A review of Patient 4’s Skilled Nurse Flow Sheet, dated 5/02/2023 did not have pulse, respiration rate or oxygen saturation documented. The residual check box was blank, and the intake record indicated one feeding at 10 am with 6 mL water flush. On 5/16/2023 at 10:00 am, a home visit was conducted with the LVN at Patient 4’s residence. Patient 4 was alert and was sitting on a baby highchair in the dining room. Patient Caregiver (CG 1) was present during the home visit. Patient 4 had an NG tube to the left nostril and taped to left cheek. LVN 1 prepared and administered a tube feeding to Patient 4. LVN 1 stated that Patient 1 is given 120 mL of Kate Farms (KD) Pediatric Standard, Vanilla, 1.2 calorie/mL by mouth and the remaining amount that Patient 4 cannot finish is administered an NG tube feeding with via feeding pump at 150 ml/hour. The LVN stated that Patient 4 did not finish 70 mL of the 120 mL KD and administered it with the feeding pump. During an interview on 5/18/2023 at 11:27 am, the DPCS stated that LVN 1 should have notified him of the update to Patient 4’s formula from Enfamil to Kate Farms and that LVN 1 should have documented the amount of feeding that was given by mouth to the patient and each amount of feeding given through the NG tube on the on the nurse’s note. e. A review of Patient 5’s Patient Profile indicated a Start of Care (SOC) on 05/02/2023, with primary diagnosis of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior], unspecified, intractable without status epilepticus (a condition when seizures cannot be completely controlled by medicines). A review of Patient 5 's Plan of Care (POC) for certification period 5/2/2023 to6/30/2023, included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to patients with complex medical needs at home in shifts) for 24 per day to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (temperature, pulse, blood pressure and respiration). The POC indicated to assess tracheostomy site (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) stoma and surrounding tissue and neck frequently especially when there are skin changes or signs and symptoms of infection which include irritation, pain, drainage, foul order or skin breakdown. The POC indicated for a trach inner cannula size 8 and be changed one to two times per shift as needed. The POC indicated to instruct patient caregiver on safety tips for oxygen therapy and oxygen at 2 liters per minute connected to the tracheostomy. The POC indicated to assess the foley catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) each shift and to change foley catheter size 18 Fr (French size) every month using aseptic technique. The POC indicated that the skilled nurse notify physician if there is a strong odor or cloudy urine, blood in urine, chills or fever above 99.4 F(Fahrenheit), lower back pain or swelling at catheter site. The POC indicated to administer gastrointestinal tube (G-tube) feedings as ordered by physician during shift, to administer Liquid Hope Supplement 7 ½ ounces, mix with 250 mL via four times a day for feeding and to flush G-tube with 250 mL of water with each feeding. The POC indicated for aspiration precautions at all times. A review of Patient 5’s Skilled Nurse Flow Sheet, dated 5/02/2023 (Shift 7am to 7pm) did not indicate during the gastrointestinal assessment that the residual was checked. The genitourinary assessment was incomplete and the foley catheter size was blank. The respiratory assessment was incomplete and did not indicate breath sounds, the amount oxygen and how oxygen was being administered, or oxygen saturation. The SN note indicated that the tracheostomy type and size was “Shorley” 6 and the trach care and trach site was blank. The SN note intake record did not indicate the description of the feedings or water flush to the patient. A review of Patient 5’s Skilled Nurse Flow Sheet, dated 5/03/2023 (Shift 7am to 7pm) did not indicate during the gastrointestinal assessment that the residual was checked. The genitourinary assessment was incomplete and the type of foley catheter and catheter care was blank. The respiratory assessment was incomplete and did not indicate breath sounds, the amount oxygen and how oxygen was being administered, or oxygen saturation. The SN note indicated that the tracheostomy type and size was “Shirley” 6 and the trach site was blank. The SN note intake record did not indicate the description of the feedings or water flush to the patient. A review of Patient 5’s Skilled Nurse Flow Sheet, dated 5/04/2023 (Shift 7am to 7pm) indicated that the vital signs and neurological, cardiovascular, gastrointestinal, genitourinary, and respiratory assessment was not completed. There was no SN note provided for the night shift on 5/2/2023 (7 pm to 7 am), 5/3/2023 (7 pm to 7 am), 5/4/2023 (7 pm to 7 am), 5/5/2023 (7 pm to 7 am), 5/6/2023 (7 pm to 7 am), 5/7/2023 (7 pm to 7am). During an interview on 5/18/2023 at 10: 58 am, the Director of Patient Care Services (DPCS) stated that the patient’s residual should have been checked marked on the nurses note and the narrative should have the amount of residual documented. The DPCS stated that the water flush after the feedings and medication should have been performed per POC with 15 to 60 mL of water and documented in the nurses note and that 1 cc or 5 cc was not an adequate amount for flushing the feeding or medication through the NG tube to the stomach. The DPCS stated that the intake record in the nurses note should indicate the type of feeding and flush and the amount given to the patient. During an interview on 5/18/2023 at 11:04 pm, the DPCS stated that the patient vitals and assessment should have been performed per POC. During an interview on 5/18/2023 at 11:35 am, the DPCS stated that the nurse should complete the patient assessment and document it on the Skilled Nurse Flow sheet. The DPCS stated that LVN 5 should have documented the complete skills nurse assessment of Patient 5 which included the foley catheter (a flexible tube that is inserted into the bladder to drain urine) size, urine output, urine characteristics such as color, appearance and odor. The DPCS further stated Patient 5’s respiratory assessment (breath sounds, cough, secretions, amount, consistency, color, oxygen and oxygen saturation) and respiratory care which included tracheostomy tube (a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide) type, size, trach care, trach site description should have been documented. The DPCS stated that the respiratory assessment was important to ensure the patient was receiving adequate oxygenation, had the correct size trach, and that the patient tracheostomy was not blocked. During an interview on 5/18/2023 at 11:55am, the DPCS stated that the night shift nurse did not have skilled nurse notes for Patient 5 from 5/2/2023 through 5/7/2023. The DPCS stated that the nurse’s notes should be completed to ensure the patient’s plan of care is followed and that there is continuity of care for the patient. A review of the (undated) HHA’s policy, “Care Planning Process,” indicated that the plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. a. A review of Patient 1's Patient Profile indicated a Start of Care (SOC) date of 09/04/2014, with primary diagnosis of anemias (not enough healthy red blood cells) due to enzyme disorder (inherited defects that results in a number of life changing or life threatening conditions). A review of Patient 1 's Plan of Care (POC) for certification period 03/26/2023 to 5/24/2023, indicated an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) 24 hours per day. POC indicated to check g-tube (gastrostomy tube – a tube inserted to the belly to bring nutrition directly to the stomach) for stomach residual (volume of fluid remaining in the stomach), if residual content is greater 30 ml (milliliter- unit of measurement) hold feeding for 30 minutes then recheck and if residual content still greater that 30 ml notify physician. POC further indicated that for nutrition and hydration Patient 1 takes Nutren Jr. 1.0 with Fiber 250 ml three times a day via g-tube at 70 to 100 ml per hour by pump as tolerated, Pedialyte 500 ml at 70 ml per hour overnight and skilled nurse (SN) can substitute Pedialyte with water if Pedialyte not available and free water 300 ml two times per day at 70 ml per hour. A review of Patient 1’s Skilled Nurse Flowsheet from 05/01/2023 to 05/17/2023 indicated that residual amount was not documented by the LVN. A review of Patient 1’s Skilled Nurse Flowsheet from 05/01/2023 to 05/17/2023 indicated that on the intake record section Patient 1 is receiving 300 ml Nutren Jr and 250 ml water. b. A review of Patient 2's Patient Profile indicated a Start of Care (SOC) date of 10/07/2015, with primary diagnosis of myotonic muscular dystrophy (genetic disorder that causes progressive muscle weakness). A review of Patient 2 's Plan of Care (POC) for certification period 04/28/2023 to 6/26/2023, indicated an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 112 hours per week. POC indicated to check g-tube for stomach residual, if residual content is greater 30 ml hold feeding for 30 minutes then recheck and if residual content still greater that 30 ml notify physician. POC further indicated that for nutrition and hydration Patient 2 takes Peptamen with Prebio 625 ml to run over 10 hours continuous via pump at night and flush with 220 ml water after every feeding. A review of Patient 2’s Skilled Nurse Flowsheet from 04/28/2023 to 05/14/2023 indicated that residual amount was not documented by the LVN. A review of Patient 2’s Skilled Nurse Flowsheet from 04/28/2023 to 05/14/2023 indicated that on the intake record section LVN is documenting two different amounts of fluids, 250 and 200 but documentation does not indicate what type of fluid is being given. c. A review of Patient 3's Patient Profile indicated a Start of Care (SOC) date of 06/15/2022, with primary diagnosis of microcephaly ( a congenital condition associated with incomplete brain development). A review of Patient 3 's Plan of Care (POC) for certification period 04/11/2023 to 6/09/2023, indicated an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 330 hours per month. POC further indicated that for nutrition and hydration Patient 3 takes Kate Farm 1.0 standard, 220 ml times three hours and then one hour off and another three hours on then another one hour off while awake. POC further indicated to flush g-tube with 40 to 50 ml of water every hour. A review of Patient 3’s Skilled Nurse Flowsheet from 05/01/2023 to 05/17/2023 indicated that on the intake record section LVN formula and water amount being provide to the patient are inconsistent from what is indicated in the POC. During an interview with Director of Patient Care Services (DPCS) on 05/18/2023, at 12:30 p.m., he stated that the plan of care is a physician order and has to be followed and if there are any changes then need to be notified so that POC can be amended. DPCS further stated that residual amount should be documented of the nursing notes on the residual section or on the nursing narratives.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to update the nutritional requirements in the plan of care for one of seven patients (Patient 4). This failure had the potential to affect the patient’s nutritional needs required for the patient’s growth and well-being. A review of Patient 4's Patient Profile indicated a Start of Care (SOC) on 11/28/2023, with primary diagnosis of Hydrocephalus (a condition in which fluid accumulates in the brain, typically in young children, enlarging the head and sometimes causing brain damage). A review of Patient 4 's Plan of Care (POC) for certification period 03/28/2023 to 5/26/2023, included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 140 hours per month to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. The POC indicated to administer nasogastric (NG, reaching or supplying the stomach via the nose) as order, nourish breastmilk/Enfamil (milk-based, iron-fortified, routine infant meal) formula 150 milliliters/hours, six feedings a day. On 5/16/2023 at 10:00 am, a home visit was conducted with the LVN at Patient 4’s residence. Patient 4 was alert and was sitting on a baby highchair in the dining room. Patient Caregiver (CG 1) was present during the home visit. Patient 4 had an NG tube to the left nostril and taped to left cheek. LVN 1 prepared and administered a tube feeding to Patient 4. LVN 1 stated that Patient 1 is given 120 mL of Kate Farms (KD) Pediatric Standard, Vanilla, 1.2 calorie/mL by mouth and the remaining amount that Patient 4 cannot finish is administered an NG tube feeding with via feeding pump at 150 ml/hour. The LVN stated that Patient 4 did not finish 70 mL of the 120 mL KD and administered it with the feeding pump. During an interview on 5/18/2023 at 10:37 am, the Director of Patient Care Services (DPCS) stated that the order for the tube feeding should have been updated on the same day that the feeding was changed. The DPCS stated that this was important to ensure that patient received the correct feeding that the doctor ordered. A review of the HHA’s policy, Care Planning Process, dated 11/2022, indicated that the plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. The policy indicated that the plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. The policy indicated that changes in the plan of care will be noted with the following documentation: A. Assessment B. Plan of care with clinical outcome goals C. Care plan with specific services/actions to be taken D. Clinical notes e. Verbal orders

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the nursing staff provided instructions or health teaching to one of seven sampled patients (Patient 4). This failure had the potential to result in the HHA's inability to provide the quality care and services for all the patients under their care. A review of Patient 4's Patient Profile indicated a Start of Care (SOC) on 11/28/2023, with primary diagnosis of Hydrocephalus (a condition in which fluid accumulates in the brain, typically in young children, enlarging the head and sometimes causing brain damage). A review of Patient 4 's Plan of Care (POC) for certification period 03/28/2023 to 5/26/2023, included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 140 hours per month to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. The POC indicated to administer nasogastric (NG, reaching or supplying the stomach via the nose) as order, nourish breastmilk/Enfamil (milk-based, iron-fortified, routine infant meal) formula 150 milliliters/hours, six feedings a day. The POC indicated to check the NG tube for residual (the amount of fluid/contents that are in the stomach) before feeding and as necessary and if residual greater than 30 mL to hold feedings for 30 minutes then recheck. If residual is still greater than 60 mL, hold feeding and call physician and notify patient caregiver (PCG). The POC indicated for aspiration precautions at all times. On 5/16/2023 at 10:00 am, a home visit was conducted with the LVN at Patient 4’s residence. Patient 4 was alert and was sitting on a baby highchair in the dining room. Patient Caregiver (PCG) was present during the home visit. Patient 4 had an NG tube to the left nostril and taped to left cheek. LVN 1 prepared and administered a tube feeding to Patient 4. LVN 1 stated that Patient 1 is given 120 mL of Kate Farms (KD) Pediatric Standard, Vanilla, 1.2 calorie/mL by mouth and the remaining amount that Patient 4 cannot finish is administered an NG tube feeding with via feeding pump at 150 ml/hour. LVN 1 stated that Patient 4 did not finish 70 mL of the 120 mL KD and administered it with the feeding pump. LVN 1 stated the residual was checked prior to starting Patient 4’s feeding. When asked if the residual amount was documented, LVN 1 stated it was not documented and that it was usually zero. When asked why checking the residual was important, LVN 1 stated it was to check that the tube was in the stomach. During an interview on 5/16/2023 at 10:50 pm, when the patient caregiver (CG 1) was asked why it was important to check the residual, PCG 1 stated it was imported because it to check the placement of the NG tube. During an interview on 5/18/2023 at 10:37 am, the Director of Patient Care Services (DPCS) stated that the residual should be checked to ensure that the patient is tolerating the feeding. The DPCS stated that checking the residual should be performed prior to the feeding as instructed in the plan of care and if the residual is high, the nurse should hold the feeding. A review of the (undated) HHA’s policy, “Administering Enteral Feeding,” indicated that to ensure that your stomach is emptying people, you should check the residual. The residual is the amount of formula or gastric just remaining in the stomach. The policy indicated that if the residual content is greater than 30 mL hold feedings for 30 minutes, then recheck. If residual content is still greater than 30 mL, notify the physician/Clinical Supervisor. The policy further indicated that if no gastric content appears, the tube may be against the lining of the stomach or the tube may be obstructed. A review of the HHA’s policy, Patient Education Process, dated 11/2022, indicated that patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by assessing the needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsibility of each clinician and will focus on: 1. Facilitating the patient's and family/caregiver's understanding of his/her health status, health care options, and consequences of options 2. Encouraging patient participation in decision-making about health care options 3. Increasing patient and family/caregiver potential to follow the plan of care 4. Maximizing care skills of the patient and family/caregiver

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to notify the doctor of Patient 6 and 7’s change of condition for two of seven sampled patients (Patient 6 and 7). This deficiency had the potential to result in serious complications to patient’s health and quality of care. a. A review of Patient 6 's Plan of Care (POC) indicated a start of care (SOC) date of 3/22/2019 with diagnoses that included other specified degenerative disease of the nervous system and microcephaly (condition in which a baby's head is significantly smaller than expected, often due to abnormal brain development), and unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). The POC indicated a certification period 12/31/2022 through 2/28/2023, which included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 40 hours per week to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. A review of Patient 6’s physician order dated 1/4/2023 indicated that “patient admitted to the hospital with diagnosis of pneumonia and to hold all Nurse Care Health Group services as of 1/4/2023 while patient remains in the hospital until further physician orders. The order was signed on 1/19/2023 by the Director of Patient Care Services (DPCS). A review of Patient 6’s physician order dated 1/5/2023 indicated that Patient 6 expired in the hospital and to discharge patient from all HHA services as the date of hospital transfer on 1/4/2023. b. A review of Patient 7's Patient Profile indicated a start of care (SOC) date of 1/28/2022, with a primary diagnosis of quadriplegia (the loss of motor and/or sensory function of the arms and legs) and other diagnosis of respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and myasthenic syndromes (a group of conditions characterized by muscle weakness (myasthenia) that worsens with physical exertion). A review of Patient 7's Plan of Care (POC) for certification period 1/28/2022 through 3/28/2022 included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 360 hours per month to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (temperature, pulse, and respiration) and medication compliance. A review of Patient 7’s physician order dated 2/2/2022 indicated that Patient 7 was unresponsive, blood pressure elevated, taken to the hospital, and admitted to the emergency room for inpatient hospital stay. The order indicated that Patient 7 would be transferred to a long-term care skilled nursing facility after hospital stay and to discharge patient from all HHA services. The order was signed on 2/25/2023 by the DPCS. During an interview on 5/18/2023 at 1:30 pm, the Director of Patient Care Services (DPCS) stated that the patient’s physician should have been notified earlier and that the time and date when the physician was notified of the patient going to the hospital should have been indicated in the patient’s clinical record. A review of the HHA’s policy, “Physician Notification of Changes,” dated 11/2022 indicated that the patient's physician will be contacted on the same day when any of the following occur: • Significant changes in the patient's condition… •Patient is to be discharged from the organization or a specific service is to be discontinued The policy indicated that the documentation of the physician notification will include: a. Date and time contacted b. Patient name c. Name of physician notified or his/her representative d. Reason for notification e. Physician's response f. Action taken or orders obtained g. Professional's signature and title

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to have qualified personnel by failing to ensure Licensed Vocational Nurse (LVN 1, LVN 2 and LVN 5) had annual training and a competency review. These failures have the potential risk for these patients not to receive quality of care and services provided by the unqualified personnel. a. A review of LVN 1 employee records indicated a date of hire on 5/28/2002. There was no current annual competency in the file. A review of LVN 1’s Record of Training for 2022 indicated lessons from 1/10/2022 through 3/25/2022. The HHA was unable to provide the training rosters for each lesson on the date completed. b. A review of LVN 2’s employee records indicated a date of hire on 8/1/2015. There was no current annual competency in the file. A review of LVN 2’s Record of Training for 2022 indicated lessons from 1/10/2022 through 3/25/2022. The HHA was unable to provide the training rosters for each lesson on the date completed. c. A review of LVN 5’s employee records indicated a date of hire on 11/25/2019.There was no current annual competency in the file. There was no skills and experience inventory in the file. A review of LVN 5’s Record of Training for 2022 indicated lessons from 1/10/2022 through 3/25/2022. The HHA was unable to provide the training rosters for each lesson on the date completed. During an interview on 5/18/2023 at 10:49 am, the Director of Patient Care Services (DPCS) stated that annual competency exams were performed every year and that it should be in the personnel files. The DPCS stated that he was responsible to make sure the competency is completed on time and is in the employee files. During an interview on 5/18/2023 at 11:13 am, the DPCS stated he was responsible for in-services and training provided to the nurses. The DPCS stated that for each in-service/lesson, there should have been an in-service sign-in sheet. A review of the HHA’s policy, “Personnel Record Contents,” dated 11/2022 indicated that the content of the personnel files for regular full or part-time personnel will include: - skills experience and inventory and competencies- initial and ongoing. A review of the HHA’s policy, “Training/In-Service Education,” dated 11/2022, indicated that the HHA would provide training and education to give personnel opportunities to learn new skills and improve/expand existing knowledge. The policy indicated for in-service education programs designed to increase competence in a specific are and improve overall organization performance of major functions and processes. The policy indicated that a record will be maintained for each session, including: A. Program objectives B. Content outline C. Speaker D. List of attendees. The policy indicated during the ongoing supervision and competency reviews, the supervisors will evaluate if the training and education has improved the competence of the organization personnel.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to follow their discharge policy by not completing a discharge summary for two of seven patients (Patient 6 and 7). This failure had the potential to affect the patient's outcome and post discharge instructions. a. A review of Patient 6 's Plan of Care (POC) indicated a start of care (SOC date of 3/22/2019 with diagnoses that included other specified degenerative disease of the nervous system and microcephaly (condition in which a baby's head is significantly smaller than expected, often due to abnormal brain development), and unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). The POC indicated a certification period 12/31/2022 through 2/28/2023, which included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 40 hours per week to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. A review of Patient 6’s Discharge/Transfer Visit/Summary dated 1/19/2023 indicated that the patient expired in the hospital and to discharge patient from all HHA services as the date of hospital transfer on 1/4/2023. The summary indicated that the reason for discharge/transfer was “expired in medical facility-hospice patient.” A review of the Patient 6’s clinical record did not indicate the person and time when the HHA was notified that Patient 6 was transferred to the hospital on 1/4/2023. During an interview on 5/18/2023 at 1:18 pm, the DPCS stated that there was no documentation of when the family of Patient 6 called and notified the HHA. The DPCS stated that the HHA notified the physician but did not document the time. The DPCS stated that the discharge summary should have been completed earlier and should have included the date and time the physician was notified and the location where the patient was transferred. b. A review of Patient 7's Patient Profile indicated a start of care (SOC) date of 1/28/2022, with a primary diagnosis of quadriplegia (the loss of motor and/or sensory function of the arms and legs) and other diagnosis of respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and myasthenic syndromes (a group of conditions characterized by muscle weakness (myasthenia) that worsens with physical exertion). A review of Patient 7's Plan of Care (POC) for certification period 1/28/2022 through 3/28/2022 included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 360 hours per month to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (temperature, pulse, and respiration) and medication compliance. A review of Patient 7’s Discharge/Transfer Visit/Summary dated 2/2/2023 indicated that the patient was transferred to the hospital by ambulance and admitted to the emergency room for inpatient hospital stay. The summary indicated that patient would be transferred to a long-term care skilled nursing facility after hospital stay and to discharge patient from all HHA services. The summary was not complete, was not signed by a clinician, and did not indicate when Patient 7’s physician was notified. During an interview on 5/18/2023 at 1:29 pm, the DPCS stated that Patient 7’s discharge summary should have indicated the person who called 911 and when the physician was notified. The DPCS stated that Patient7’s documentation was done late and should have been completed earlier. The DPCS further stated he used the wrong form and should have completed the non-visit discharge summary form for both Patient 6 and 7. The HHA’s policy titled " Discharge Summary, dated 11/2022 indicated that each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include as appropriate: A. The date of discharge, the date the physician and patient informed of discharge. A. The reason for discharge B. The name of the organization to which the patient is being transferred, if applicable C. The status of problems identified at admission and during the provision of care. D. The progress towards goals/desired outcomes E. Medical status at discharge including continuing symptom management needs. F. The overall status of the patient G. A summary of the care or services provided. The policy indicated that the discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. A copy of the discharge summary will be provided to the patient's physician within 5 business days from the day of the discharge. The organization will complete all necessary audits to determine the completeness of the patient's clinical record within 30 days of the last home visit and discharge date. The discharge record will be organized according to policy for clinical records contents and removed from the active files.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to: 1) Complete the Skill Nurse Flow Sheet timely for four of seven sampled patients, (Patient 3, 4, 5, and 6). 2) Document the correct reason for missed visits for three of seven sampled patients, (Patient 2, 4, and 6) This deficient practice placed the patient at a potential risk for not receiving skilled nursing care as needed. a. A review of Patient 4's Patient Profile indicated a Start of Care (SOC) on 11/28/2023, with primary diagnosis of Hydrocephalus (a condition in which fluid accumulates in the brain, typically in young children, enlarging the head and sometimes causing brain damage). A review of Patient 4 's Plan of Care (POC) for certification period 03/28/2023 to 5/26/2023, included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 140 hours per month to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. The POC indicated a pediatric diet/hydration of breast/milk formula, 150 milliliters (mL)/hour, six feedings/day. The POC indicated that in the event an HHA employee is not available to perform a scheduled assignment, the HHA will attempt to fill the assignment with another available nurse. If adequately trained staff is not available, the HHA will notify the family/patient caregiver (PCG) as soon as a possible and the family/PCG will assume care. A review of Patient 4’s Skilled Nurse Flow Sheet, dated 5/01/2023 indicated that the pulse, respiration rate or oxygen saturation was not documented. The residual check box was blank, the flushes solution was water with amount 1 milliliter (mL) with feedings and medications. The intake record indicated one feeding at 10 am with 2 mL water flush. The flow sheet was not signed by a clinician. A review of Patient 4’s Skilled Nurse Flow Sheet, dated 5/02/2023 indicated that the pulse, respiration rate or oxygen saturation was not documented. The residual check box was blank, and the intake record indicated one feeding at 10 am with 6 mL water flush. The flow sheet was not signed by a clinician. A review of Patient 4’s Missed Visit noted dated 5/15/2023 indicated that the reason for the missed visit was due to “Other: Unable to staff due to Coronavirus Disease 19 (COVID-19, a respiratory viral infection that affects primarily the lungs and results in cough and difficulty breathing).” The note indicated in the comments section that the HHA was unable to staff 92 hours for the month of April and that the patient caregiver assumed all care. During an interview on 5/17/2023 at 4:00 pm, the Director of Patient Care Services (DPCS) stated that the designated nurse for Patient 4 went on vacation in April and did not have Covid-19. The DPCS stated he did not enter the correct reason for the missed visit. b. A review of Patient 5 's Plan of Care (POC) for certification period 5/2/2023 to6/30/2023, included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to patients with complex medical needs at home in shifts) for 24 per day to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and neurological status and to perform vital signs every shift (temperature, pulse, blood pressure and respiration). A review of Patient 5’s Skilled Nurse Flow Sheet, dated 5/02/2023 (Shift 7am to 7pm) was incomplete. The flow sheet did not indicate during the gastrointestinal assessment that the residual was checked. The genitourinary assessment was incomplete and the foley catheter size was blank. The respiratory assessment was incomplete and did not indicate breath sounds, the amount oxygen and how oxygen was being administered, or oxygen saturation. The SN flow sheet indicated that the tracheostomy type and size was “Shorley” 6 and the trach care and trach site was blank. The SN flow sheet intake record did not indicate the description of the feedings or water flush to the patient. The flow sheet was not signed by the clinician. A review of Patient 5’s Skilled Nurse Flow Sheet, dated 5/03/2023 (Shift 7am to 7pm) indicated that residual was not checked. The genitourinary assessment was incomplete and the type of foley catheter and catheter care was blank. The respiratory assessment was incomplete and did not indicate breath sounds, the amount oxygen and how oxygen was being administered, or oxygen saturation. The SN note indicated that the tracheostomy type and size was “Shirley” 6 and the trach site was blank. The SN flow sheet intake record did not indicate the description of the feedings or water flush to the patient. The flow sheet was not signed by the clinician. A review of Patient 5’s Skilled Nurse Flow Sheet, dated 5/04/2023 (Shift 7am to 7pm) indicated that the vital signs and neurological, cardiovascular, gastrointestinal, genitourinary, and respiratory assessment was not completed. There was no SN note for the night shift on 5/2/2023 (7 pm to 7 am), 5/3/2023 (7 pm to 7 am), 5/4/2023 (7 pm to 7 am), 5/5/2023 (7 pm to 7 am), 5/6/2023 (7 pm to 7 am), 5/7/2023 (7 pm to 7am). c. A review of Patient 6 's Plan of Care (POC) indicated a start of care (SOC) date of 3/22/2019 with diagnoses that included other specified degenerative disease of the nervous system and microcephaly (condition in which a baby's head is significantly smaller than expected, often due to abnormal brain development), and unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). The POC indicated a certification period 12/31/2022 through 2/28/2023, which included an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 40 hours per week to assess for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and neurological status and to perform vital signs every shift (oxygen saturation, temperature, pulse, and respiration) and medication compliance. The POC indicated that a trained patient caregiver is deemed safe to assume car for patient when the HHA is not in the home and may administer medications and treatments. The POC indicated that the PCG will be responsible for all care when the HHA is not on duty. This care includes, but not limited to, administering tube feeding, medications, treatments, and personal care. A review of A review of Patient 6’s Missed Visit noted dated 2/13/2023 indicated that the reason for missed visit was “Other: Unable to staff due to Covid-19.” The note indicated in the comments section that the agency was unable to staff 144 hours for the month of January. A review of Patient 6’s Physician Order dated 1/4/2023 indicated that Patient 6 was admitted to the hospital with a diagnosis of pneumonia (condition where inflammation and fluid in the lungs caused by a bacterial, viral or fungal infection makes it difficult to breathe). The order indicated to hold all HHA services as of 1/4/2023 while patient remains in the hospital until further physician orders. A review of Patient 6’s Physician Order dated 1/5/2023 indicated that Patient 6 expired (died) in the hospital and to discharge patient from all HHA services as the of hospital transfer on 1/4/2023. During an interview on 5/17/2023 at 4:21 pm, the DPCS stated that the reason on the missed visit note for Patient 2, Patient 4 and Patient 6 were not the right reason, was a mistake and not due to staff having Covid-19. The DPCS stated that the physician was notified every month of the missed visits and that he had been using the reason for Covid-19 as a template. The DPCS stated he was not notified when the nurse missed a visit and had to follow up with the staffing coordinator (SC). The DPCS stated the communication between the SC and DPCS needed to be improved. A review of Patient 6’s Skilled Nurse Flow Sheet, dated 1/2/2023 indicated that note was signed by clinician on 1/23/2023. A review of Patient 6’s Skilled Nurse Flow Sheet, dated 1/3/2023 indicated that note was signed by clinician on 1/23/2023. A review of the HHA’s policy, “Ongoing Care Documentation Note Submission” dated 11/2022, indicated that all documentation must be completed and submitted to the office within the scheduled deadline from the date of the visit. The policy indicated that the documentation due to the office on a weekly basis (by the end of business day on Monday): Skilled nursing flow sheet. A request for the HHA’s policy on accuracy of documentation was required by was not provided. a. A review of Patient 2's Patient Profile indicated a Start of Care (SOC) date of 10/07/2015, with primary diagnosis of myotonic muscular dystrophy (genetic disorder that causes progressive muscle weakness). A review of Patient 2 's Plan of Care (POC) for certification period 04/28/2023 to 6/26/2023, indicated an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 112 hours per week. A review of Patient 2’s Missed Visit noted dated 05/15/2023 indicated that the reason for missed visit was “Other: Unable to staff due to Covid-19.” The note indicated in the comments section that the agency was unable to staff 268 hours for the month of April. During an interview with the Staffing Coordinator (SC) on 05/18/2023, at 1:45 p.m., she stated missed visit was not due to COVID-19 and it was an error in documentation. SC stated that reason for the missed visit was because Patient 2’s mom refused visits and she is using another agency for those hours. b. A review of Patient 3's Patient Profile indicated a Start of Care (SOC) date of 06/15/2022, with primary diagnosis of microcephaly ( a congenital condition associated with incomplete brain development). A review of Patient 3 's Plan of Care (POC) for certification period 04/11/2023 to 6/09/2023, indicated an order for a Licensed Vocational Nurse (LVN) shift care (private duty nursing care offered to children with complex medical needs at home in shifts) for 330 hours per month. A review of Patient 3’s Skilled Nurse Flow Sheet dated 05/09/2023, indicated that the LVN did not complete her documentation. During an interview with Director of Patient Care Services (DPCS) on 05/18/2023, at 12:30 p.m. and 2:50 p.m., he stated that completed notes should be submitted weekly. DPCS stated that Patient 3’s nursing note dated 05/09/2023 should have been submitted and completed by 05/15/2023.