Every finding on record at Nurse Care Home Health Agency Inc

Purpose of visit: Recertification and Relicensure Survey Entrance conference date 06/02/2026 The census was -3 Licensed and Certified Patients– 0 Licensed Home Health Patients– 0 Personal Assistance Services – 3 The Home Health Agency was compliant with Emergency Preparedness.

Purpose of visit: Recertification and Relicensure Survey Entrance conference date 06/02/2026 The census was -3 Licensed and Certified Patients– 0 Licensed Home Health Patients– 0 Personal Assistance Services – 3 Abbreviations: Adm – Administrator AV -arteriovenous CMS – Centers for Medicare and Medicaid Services dl- deciliter DON – Director of Nurses or Supervising Nurse EMR – Electronic Medical Record ESRD-End Stage Renal Disease IQIES – Internet Quality Improvement and Evaluation System HHA- Home Health Agency Mg- milligrams OASIS – Outcome and Assessment Information Set OT- Occupational Therapist POC- Plan of Care QAPI- Quality Assurance and Performance Improvement RN-Registered Nurse SN-Skilled nurse SOC- Start of Care ST-Speech Therapist #- number %- percentage

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record reviews and interviews the Agency failed to encode and electronically transmit each completed OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) assessment to the CMS system within 30 days of completing the patient’s assessment for 32 of 49 OASIS assessments submitted from 05/30/2025 to 05/29/2026. This failure prevented CMS from analyzing patient’s data and the Agency’s performance in comparison to other agencies, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. Findings: Review of the HHA Error Summary by Agency report in IQIES (CMS system to manage provider and patient information and ensure quality healthcare) on 5/29/2026 revealed 32 late OASIS assessment submissions with error code 3330 (code for a late submission greater than 30 days after the patient’s assessment completion date) of 49 OASIS assessments submitted by the Agency for report period 05/30/2025 to 05/29/2026. The report contained a late submission rate of 65.31%. An entrance conference interview was conducted with the Adm/DON/Agency Owner on 6/02/2026 at 11:45am. When asked about the Agency’s policy and procedures for OASIS assessment submissions. The Adm/DON/Agency Owner stated that the patient’s OASIS assessment “Must be submitted within 30 days” of the patient’s assessment completion date to CMS. The Adm/DON/Agency Owner stated “The person (RN) who completed the OASIS assessment was responsible” for the OASIS assessment submission to CMS. The Adm/DON/Agency Owner stated that the OASIS assessments were not reviewed by a Quality Assurance review process. The Adm/DON/Agency Owner stated, “Once the nurse completed the admission, they (the RN) submitted it through IQIES.” When asked about the Agency’s process of monitoring the timeliness of OASIS assessment submissions to CMS. The Adm/DON/Agency Owner did not directly answer the question and stated “We (Agency RNs) strive to submit it (OASIS assessments to CMS) on time. Sometimes there is a glitch with the system (IQIES). Sometimes we (Agency RNs) thought it (OASIS assessment) was submitted, and it (OASIS assessment submission) had not gone through or IQIES was down. Those are the major issues we (the Agency RNs) had.” The Adm/DON/Agency Owner stated “We (the Agency RNs) tried to educate and remind ourselves” to submit OASIS assessments to CMS with in the 30 days and “find ways to go back and check” IQIES to verify that the OASIS assessment submission went through. The Adm/DON/Agency Owner stated, “When we (The Agency RNs) go back later” to verify the submission went through to CMS “the 30 days had already passed.” The Surveyor shared the findings of the late OASIS assessment submissions located in IQIES. When asked about the late OASIS assessment submissions. The Adm/DON/Agency Owner stated, “Usually it (reason for the late OASIS assessment submission) was a system (IQIES) issue, by the time you realized it (OASIS assessment submission) errored or didn’t go through you had to resubmit and it was always way passed the due date.” When asked about the Agency’s OASIS validation reports (system generated documents provided by CMS that verified whether the submissions of the OASIS Home Health patients’ assessments were successfully accepted or rejected), the Adm/DON/Agency Owner stated that the Agency did not save or print out the validation reports to confirm the status of the OASIS assessment submissions. The Adm/DON/Agency Owner stated that she printed the validation reports only when requested by the Agency’s billing contractor. When asked about the potential patient outcome for late OASIS assessment submissions. The Adm/DON/Agency Owner stated “They (CMS) won’t be able to assess the quality of care” provided to the patients by the Agency. The Surveyor requested the Agency’s OASIS validation reports from the Adm/DON/Agency Owner on 6/04/2026 at 9:19am. The Adm/DON/Agency Owner stated that she would save the validation reports from IQIES and email the validation reports to the Surveyor. The Adm/DON/Agency Owner stated when the Agency’s billing contractor called her for the OASIS assessment validation reports “I printed it (validation report) from IQIES that is when I noticed that the OASIS submission did not go through and had to be resubmitted.” The Adm/DON/Agency Owner stated that the OASIS validation reports were not printed or viewed after the OASIS patient assessment was submitted unless requested by the Agency’s billing contractor. Record review of the Agency’s OASIS validation reports for period 6/01/2025 through 06/04/2026 provided by the Adm/DON/Agency Owner on 6/04/2026 revealed 32 late OASIS assessment submissions with error code 3330 (code for a late submission greater than 30 days after the patient’s assessment completion date). Record review of the Agency’s QAPI summary dated 7/31/2025 and signed by the Adm/DON/Agency Owner/Governing Board Member and the Alternate Administrator/Governing Board Member contained a Performance Improvement Project for the late OASIS assessment submissions with a goal to reduce the late submissions to “2% by the end of 2025.” Record review of the QAPI summary dated 1/31/2026 and signed by the Adm/DON/Agency Owner/Governing Board Member and the Alternate Administrator/Governing Board Member read “There were 38 (OASIS) errors in 41 forms in the second half of 2025…Error #3330 (code for a late submission greater than 30 days after the patient’s assessment completion date), late OASIS had 25 of 41 forms submitted more than 30 days…for an error rate of 60.98%...Recommendation. Will continue to monitor monthly with a report to the Administrator and a biannual report to the Governing Board.” Record review of the Agency’s undated policy binders provided by the Adm/DON/Agency Owner on 6/05/2026 did not contain a specific timeline policy for OASIS assessment submissions. An interview was conducted with the Adm/DON/Agency Owner/Governing Board Member on 6/05/2026 at 5:32pm. The Surveyor shared the findings on the OASIS validation reports, late OASIS assessment submissions reported on the QAPI summary, and the Agency’s initiation of a Performance Improvement Project for late OASIS submissions. When asked about the late OASIS assessment submissions, the Adm/DON/Agency Owner stated “I just have to be quicker in finishing the OASIS (patient assessments). Maybe I didn’t finish them (OASIS patients’ assessments) on time. Sometimes I finished it (OASIS patient assessment) on day 30 and received an error the following day.” Review of the Agency’s undated “Initial Patient Assessment / Patient Admission” policy read in part “ Each patient will receive a patient specific, comprehensive assessment that incorporates OASIS data set for Medicare/ Medicaid patients, completed by a Registered Nurse to determine the immediate care and support needs of the patient; and for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The Agency will ensure safe, timely, accurate data collection and transmission of OASIS data. In addition, the Agency will ensure: the encoded OASIS data accurately reflects the patient's status at the time of assessment; Data is transmitted at least once a month; electronically reporting OASIS Data on all applicable patients in a format that meets CMS electronic data and edit specifications; conducting clinical and data entry audits and a process to verify that collected OASIS data is consistent with reported OASIS data; identifying and addressing any discrepancies in data collected and reported; an alternate plan is in place when it is unable to submit OASIS data to the state agency. Review of the Agency’s undated “Patient Assessment Guidelines” policy read in part “ The Agency will utilize and adhere to a defined comprehensive assessment to identify the patient’s needs for home care and that meets the patient's medical, nursing, rehabilitative, social and discharge planning needs. The Comprehensive Assessment and OASIS data collection will be completed by primary provider- a Registered Nurse, Physical Therapist, Speech Therapist (or Occupational Therapist on recertification). Other qualified agency professionals who have the necessary skills and training and comply with all federal and state laws and regulations will perform applicable assessments per discipline, as ordered by the physician…An assessment performed due to an intra-agency referral will be completed as follows: Nursing 48 hours; Physical Therapy 4 days; Occupational Therapy 4 days; Speech Therapy 4 days; Medical Social Worker 4 days.”

Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the Agency failed to ensure the completion of the OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) data items on the patient’s initial comprehensive assessment which included the patient’s supportive assistance status and integumentary status for 2 (Patients 4 and 6) of 7 discharged patient records reviewed. The failure to complete all required elements on the patient’s OASIS comprehensive assessment potential placed patients at risk for unmet needs and poor quality of care. Findings: Record review of discharged Patient 4 in the Agency’s EMR system revealed a start of care date of 9/18/2025 and a discharged date of 9/24/2025. Records contained a Start of Care OASIS comprehensive assessment dated 9/18/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented under the “Homebound Status” portion of the assessment that the patient had a history of a Cerebrovascular Accident (a condition or “stroke” that can lead to long term disability or death when blood flow to the brain is blocked or a blood vessel in the brain bursts) which caused “loss of lower extremities (legs), weakness, and limited mobility.” The Adm/DON/Agency Owner documented that the patient had “severe functional impairments, fatigue, dyspnea (shortness of breath) on exertion, and high fall risk, which caused dependence on wheelchair for mobility and need for assistance with all activities of daily living for any distance and frequency outside the home.” The Adm/DON/Agency Owner documented in the intervention section that the “Wound assessment was completed on bilateral (right leg and left leg) amputation sites with inspection for skin breakdown, drainage, or infection, and dressings were changed per orders.” The Adm/DON/Agency Owner documented that the patient had a history of “End stage Renal Disease (condition in which the kidneys can no longer filter waste and excess fluids) on hemodialysis (procedure in which a machine with a specialized filter continuously pumps blood out of the body to filter out waste and excess fluid before returning the cleaned blood to the body). The Adm/DON/Agency Owner documented “Patient’s dialysis access site was inspected for signs of infection or complications.” The Adm/DON/Agency Owner documented that the patient had a history of “Diabetes (long term condition in which the body cannot properly process or use glucose or “sugar” for energy). The Adm/DON/Agency Owner also documented that the patient was on a medication to prevent blood clots and was at “risk of bleeding.” Further review of the patient’s SOC OASIS comprehensive assessment revealed no documentation under “skin turgor (elasticity and firmness)” “skin color” or “skin condition” within the section labeled “Integumentary (body’s outer covering consisting of skin, hair, nails, and oil and sweat producing glands).” The assessment did not contain documentation of the appearance or condition of the surgical wounds to the patient’s right and left leg, and the details of the wound care that was completed. The SOC OASIS assessment also did not contain any documentation under the section “safety measures” within the “Supportive Assistance” section of the assessment, which included the option to select 24-hour supervision, bleeding precautions, diabetic precautions, fall precautions, and standard/infection precautions. Record review of discharged Patient 6 in the Agency’s EMR system revealed a start of care date of 10/24/2025 and a discharged date of 12/22/2025. Records contained a Start of Care OASIS comprehensive assessment dated 10/24/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented under the “Homebound Status” portion of the assessment that the patient had a history of “Type 2 Diabetes Mellitus (long term condition in which the body cannot properly process or use glucose or “sugar” for energy) with Hyperglycemia (high blood sugar).” The Adm/DON/Agency Owner documented that the patient had “experienced multiple falls within the past 12 months” and was a “significant fall risk.” The Adm/DON/Agency Owner also documented that the patient was on a medication to prevent blood clots with a “bleeding risk.” Further review of the patient’s SOC OASIS comprehensive assessment revealed no documentation under “skin turgor,” “skin color,” or “skin condition” within the section labeled “Integumentary.” The assessment also did not contain any documentation under the section “safety measures” with in the “Supportive Assistance” section of the assessment, which included the option to select bleeding precautions, diabetic precautions and fall precautions. An interview was conducted with the Adm/DON/Agency Owner on 6/05/2026 at 5:32pm. The Surveyor shared the findings of Patients 4 and 6. When asked why the “safety measures” and skin assessment sections of the SOC OASIS comprehensive assessments were not completed for Patients 4 and 6. The Adm/DON/Agency Owner stated “I don’t know. Maybe an oversite. I am surprised. It (the Agency’s EMR system) won’t let you (the Agency RN) advance (to another section of the assessment documentation) when it (the safety measures or skin assessment) is not completed. It (the EMR system) will prompt you (the Agency RN) that something is missing and it (EMR system) lists the numbers (of the section of the OASIS assessment) for you (the Agency RN) to go and do.” When asked about the potential patient outcome for not completing a thorough assessment of all required OASIS items on the comprehensive assessment. The Adm/DON/Agency Owner stated “You (the RN) can miss some things that the patient will need. Let’s say there’s a wound on the back of the (patient’s) leg or a skin tear. If you don’t do a full assessment then you’re (the RN) going to miss what (orders for wound treatment and wound care) to do for the patient.” Review of the Agency’s undated “Initial Patient Assessment / Patient Admission” policy read in part “ Each patient will receive a patient specific, comprehensive assessment that incorporates OASIS data set for Medicare/ Medicaid patients, completed by a Registered Nurse to determine the immediate care and support needs of the patient; and for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The Agency will ensure safe, timely, accurate data collection and transmission of OASIS data. In addition, the Agency will ensure: the encoded OASIS data accurately reflects the patient's status at the time of assessment…A Comprehensive Assessment will include at minimum the following information and meet this criteria: Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the secretary must include…supportive assistance…integumentary status; Physical assessment/Review of systems; Safety…”

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the Agency failed to ensure the completion of an updated OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) Comprehensive Assessment at discharge for 2 (Patients 2, and 7) of 7 discharged patients’ records reviewed in that: The Agency failed to complete an updated OASIS Comprehensive Assessment within two days of a patient’s/caregiver’s discharge request for Patient 2. The Agency failed to complete an updated OASIS Comprehensive Assessment within two days of the knowledge of a discharge for Patient 7. This failure prevented CMS from analyzing the discharged patient’s data and the Agency’s performance in comparison to other agencies at the time of the patient’s discharge, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. Findings: Review of the Agency’s undated Skilled Home Health Patient list provided by the Adm/DON/Agency Owner on 6/02/2026 revealed an active patient census of 0. Record review of discharged Patient 2 in the Agency’s EMR system revealed a start of care date of 8/07/2025 and a discharged date of 10/05/2025. Records contained a Home Health Certification and Plan of Care for period 8/07/2025 to 10/05/2025 signed by the Adm/DON/Agency Owner. The POC contained a primary diagnosis of “Type 2 Diabetes Mellitus (long term condition in which the body cannot properly process or use glucose or “sugar” for energy) with Diabetic Neuropathy (nerve damage caused by long-term high blood sugar),” a secondary diagnosis of “ Acute Embolism (blockage of a blood vessel caused by a traveling blood clot) and Thrombosis (blood clot that formed inside a blood vessel) of Deep Vein of unspecified Lower Extremity (leg),” with a nurse visit frequency of once a week for week 1, then twice a week for 5 weeks, then once a week for 3 weeks. Record review of discharged Patient 2 revealed nursing visits dated 8/7/2025 (SOC assessment), 8/11/2025, 8/14/2025, 8/21/2025, and 8/25/2025 for assessment of the patient, and wound care to patient’s right leg and left leg, signed by the Adm/DON/Agency Owner. Records contained patient requested missed visit communication notes and physician notifications dated 8/18/2025 and 8/28/2025 signed by the Adm/DON/Agency Owner. Record review of discharged Patient 2 revealed a Nurse Clinical Progress Note dated 9/1/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented the assessment of the patient and completed the wound care to the patient’s left lower leg. Review of the entire visit note did not contain any evidence of discharge planning or a request by the patient to discontinue Home Health Services. Record review of discharged Patient 2 revealed a Nurse Clinical Progress Note dated 9/04/2025 assigned to the Adm/DON/Agency Owner. The progress note did not contain any documentation or evidence that the patient assessment was completed. Records did not contain a missed visit or communication note dated 9/04/2025. Further review of discharged Patient 2’s records revealed no scheduled nursing visits after 9/04/2025 until the patient’s discharge on 10/05/2025. The patient’s records did not contain any communication or missed visit notes that provided a reason why the nursing visits were not scheduled. Record review of discharged Patient 2 revealed a Discharge From Agency note dated 10/05/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner check marked the box “Patient remained in the community (with formal assistive services) under the question “Where is the patient after discharged from your agency?” The Adm/DON/Agency Owner documented the discharge instructions provided to the patient and caregiver and that the “patient was instructed to contact the home health of their choice for any future home health needs…” Record review of discharged Patient 2 revealed a Discharge Summary dated 10/05/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner check marked the box “Patient request” under “Reason for discharge.” Record review of discharged Patient 7 revealed a start of care date of 6/12/2025 and a recertification “Home Health Certification and Plan of Care” for period 10/10/2025 to 12/08/2025 signed by the Adm/DON/Agency Owner on 10/06/2025. The POC contained a primary diagnosis of “ Hypertensive Heart Disease (thickening of the heart muscle due to high blood pressure) with Heart Failure (heart not pumping blood as it should to meet the body’s needs) with a nurse visit frequency of twice a week for week one with 2 as needed visits. Record review of discharged Patient 7 revealed completed nursing visits dated 10/15/2025, 10/22/2025, 10/29/2025, 11/05/2025, 11/12/2025, 11/19/2025, and 11/26/2025. Further review of the patient’s records in the Agency’s EMR system did not contain evidence of any scheduled nursing visits after 11/26/2025, missed visit notifications, communication notes, OASIS discharge comprehensive assessment, or a discharge summary. Record review of discharged Patient 7’s “Nursing Clinical Progress Note” dated 11/26/2025 signed by the Adm/DON/Agency Owner contained a section labeled “Discharge Planning.” The Adm/DON/Agency Owner check marked the boxes that read “Discharge planning discussed with Patient and Caregiver” and “Plan to discharge and received discharge notices per Agency policy and procedures.” Further review of the Progress Note did not contain additional information on discharge planning or the patient’s planned discharge date. The Surveyor attempted a phone interview with Patient 2 on 6/05/2026 at 11:13am. The patient was not available for an interview. A phone interview was conducted with Patient 7’s primary Caregiver #8 on 6/05/2026 at 11:27am. When asked about the Home Health Services received by the Agency. Caregiver #8 stated that she was pleased with the care provided to the patient by the Adm/DON/Agency Owner and Patient 7 was “well taken care of.” When asked when a nurse from the Agency last saw Patient 7. Caregiver #8 stated “Last November (2025).” Caregiver #8 stated after the last nursing visit (11/26/2025) “He (Patient 7) was doing good, and home health was not necessary at that time (after 11/26/2025).” Caregiver #8 stated that she (Caregiver #8) requested to put the nursing visits on “hold during the holidays and wait until the beginning of the year (2026)” and that Caregiver #8 would call the Agency with any patient needs. Caregiver #8 stated that the Adm/DON/Agency Owner told her that Patient 7 would need to be “renewed” and reviewed for eligibility for continued services at the “beginning of the new year.” Caregiver #8 stated that the patient was initially eligible for home health services due to a toe amputation (surgical removal) and was seen by the wound clinic for wound care “for a month or two.” Caregiver #8 stated the wound healed and the patient “no longer qualified for the waiver” for services. When asked if a discharge visit had been completed by the Adm/DON/Agency Owner, Caregiver #8 stated, “I’m not sure.” An interview was conducted with the Adm/DON/Agency Owner on 6/05/2026 at 5:32pm. When asked about the Agency's policy and process on patient discharges. The Adm/DON/Agency Owner stated that the Agency nurse provided the patient or caregiver with a discharge “five-day notice” when the patient’s goals were met and discharge planning was discussed. The Adm/DON/Agency Owner stated sometimes the patient’s discharge was “unplanned” due to the patient “going out of town for a while or not coming back or they die.” The Surveyor shared the findings for Patient 2. The Adm/DON/Agency Owner stated that Patient 2 was seen by the “the wound clinic” and Caregiver #9 requested the patient’s “discharge.” When asked when Caregiver #9 requested Patient 2’s discharge. The Adm/DON/Agency Owner stated that she was notified of the request for discharge prior to the missed visit on 9/4/2025 but could not recall the date. When asked why the patient’s OASIS discharge and summary were not completed within two days of Caregiver 9#'s request for the patient’s discharge. The Adm/DON/Agency Owner stated, “Because every time I went (to the patient’s house) they (Patient 2 and Caregiver #9) would not be at the house and missed the visit.” When asked why there were no communication notes documenting Caregiver #9’s request for the patient’s discharge or documentation for the missed visits. The Adm/DON/Agency Owner stated, “I should have put in missed visits notes.” The Adm/DON/Agency Owner did not provide any additional information on Patient 2’s discharge. In a continued interview with the Adm/DON/Agency Owner, the Surveyor asked about the Agency’s discharge of Patient 7. The Adm/DON/Agency Owner stated that the patient was “discharged last year sometime.” The Adm/DON/Agency Owner stated the patient “had an amputated toe that healed so he was discharged.” The Surveyor shared the findings of the missing discharge OASIS assessment, discharge summary, and Patient 7’s active status in the agency’s EMR system. When asked why Patient 7’s OASIS discharge and summary were not completed with two days of discharge. The Adm/DON/Agency Owner stated “I don't know. Something is really wrong with this (EMR) system... I don't know if it's one of the updates they (EMR system vendor) did and it (the update) wiped everything (Patient 7’s OASIS discharge assessment, communication notes, and discharge summary). The patient should be discharged because when (Caregiver #8) called me I said we (The Agency) need orders from the doctor's office before we can start (home health) again…I have to go in and look (in the EMR system) to find out what happened.” The Adm/DON/Agency Owner reviewed Patient 7’s records in the Agency’s EMR system and verified the missing OASIS discharge assessment and discharge summary. The Adm/DON/Agency Owner stated “I got locked out (of the Agency’s EMR system) for some time too so that also could be the issue. I had issues with them (the EMR system vendor) about billing, and they (the EMR system vendor) locked me out (of the EMR system) so that could also be a setback, the reason why I couldn't complete my stuff (OASIS discharge assessment, communication notes and discharge summary).” When asked about the potential patient’s outcome for not following the Agency’s discharge policy. The Adm/DON/Agency Owner stated that the late completion of the patient’s discharge “resulted in the late OASIS (discharge assessment submission). I think it’s not even safe for the Agency because if anything happens to the patient it looks like the patient was current with the Agency, so the Agency will be held accountable during that time frame. As for the patients in their minds, they know the nurse discharged them because the nurse talked to them about the discharge.” Review of the Agency’s undated “Patient Discharge” policy read in part “The Agency will assess each patients discharge planning and/or continuing care needs on an ongoing basis and will involve the physician the patient, and the caregiver in the planning process. The Agency will discharge the patient when the patient meets discharge criteria. The Agency will provide appropriate discharge planning and notification per regulations. The Agency will complete a discharge assessment which includes OASIS data for Medicare/ Medicaid patients as required by CMS, upon discharge, unless patient is transferred to an inpatient facility… The agency will provide notice to eligible patients of their right to expedited determinations when their period of covered care ends. The Agency will deliver the Notice of Medicare Non-Coverage to the patient (or authorized representative), at least two calendar days before Medicare covered services and/or the second to last day of service if care is not provided daily… Discharge assessment and five-day notice. Planning for patient discharge. Planning for discharge will begin after evaluation of the data/information gathered during the Initial Comprehensive Assessment. Changes in the patient's needs during the provision of care will be identified and assessed on an ongoing basis through interdisciplinary case conferences, progress notes and comprehensive assessments. The data/information and patient/caregiver participation utilized in planning for discharge may be evidence on the following: Initial Comprehensive Assessment form; progress notes; and case conference documentation… The agency may transfer or discharge a client without five days’ notice: Upon the patient’s request… Medical record documentation for discharge includes but is not limited to: progress towards goals/ Discharge Summary; Discharge Comprehensive Assessment (including the OASIS data for Medicare/Medicaid patients); Discharge orders, if required. The Discharge Assessment is completed within 48 hours of knowledge of discharge. The OASIS Discharge Assessment for Medicare/ Medicaid patients is completed by the last discipline in the home (RN, PT, OT, or ST). In the event that the discharge is not planned, the OASIS data is based on the last assessment by the RN, PT, OT, or ST…”

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 record reviews and interviews the Agency failed to ensure that the patient’s individualized plan of care for 5 (Patients 2,3,4,6 and 7) of 7 discharged patients’ records reviewed included all required items: All necessary interventions to address the Diabetes primary diagnosis for Patients 2, 3, and 6. All necessary interventions to address the underlying risk factors of the dialysis access site for Patient 4. All patient specific interventions related to anticoagulation (blood thinner) medication use for Patients 2, and 7. This failure affected the care provided by the Agency nurse and potentially placed the patients at risk for hospitalization and poor health outcomes. Findings: Record review of discharged Patient 2 in the Agency’s EMR system revealed a start of care date of 8/07/2025 and a discharged date of 10/05/2025. Records contained a Start of Care OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) comprehensive assessment dated 8/07/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented patient’s primary diagnosis as “Type 2 Diabetes Mellitus (long term condition in which the body cannot properly process or use glucose or “sugar” for energy) with Diabetic Neuropathy (nerve damage caused by long-term high blood sugar).” Adm/DON/Agency Owner documented “Blood sugars have been unstable, fluctuating from 120 to 260; blood sugar today is 160” and “Skilled nursing will be utilized for…insulin injection…Skilled nursing will be utilized for education of: insulin administration.” The Adm/DON/Agency Owner’s documentation read “Patient instructed to report blood sugars consistently less than 70 mg/dl or greater than 250 mg/dl to physician.” The Adm/DON/Agency Owner documented “Blood sugar monitoring performed” with a plan to monitor “blood sugar trends” during the next visit. The Adm/DON/Agency Owner documented “Skilled nurse communicates…blood sugar…and any abnormal results to the physician as indicated.” The Adm/DON/Agency Owner also documented that the patient’s goals were to “decrease the risk for blood clots and manage anticoagulant (blood thinner) therapy safely with nurse monitoring and reporting of abnormal findings” and to “monitor and maintain stable blood sugar levels with education on insulin administration and diabetes management.” The Adm/DON/Agency Owner documented “Teaching provided on risk of bleeding and precautions…and monitoring for abnormal bleeding. Patient instructed to notify physician immediately if any of these occur.” Further review of the patient’s assessment revealed no blood sugar parameters for notification of the physician by the Agency’s nurse. The assessment also did not contain the frequency of the blood sugar checks or who was to perform the blood sugar checks. Record review of discharged Patient 2 revealed a Home Health Certification and Plan of Care for period 8/07/2025 to 10/05/2025 signed by the Adm/DON/Agency Owner. The POC contained a primary diagnosis of “Type 2 Diabetes Mellitus with Diabetic Neuropathy,” a secondary diagnosis of “ Acute Embolism (blockage of a blood vessel caused by a traveling blood clot) and Thrombosis (blood clot that formed inside a blood vessel) of Deep Vein of unspecified Lower Extremity (leg).” with a nurse visit frequency of once a week for week 1, then twice a week for 5 weeks, then once a week for 3 weeks. The POC contained the medications Metformin (oral medication to lower blood sugar) 500 mg two tablets twice a day, Insulin Aspart (a fast-acting injectable medication administered under the skin to lower blood sugar) 100 units/ml, not to exceed 50 units before meals and at bedtime, and Apixaban (blood thinning medication to treat blood clots) 5mg 1 tablet twice a day. The POC read in part “ SN to assess diabetic status…and diabetic management. SN may perform insulin administration and/or prefill insulin syringes as needed if patient/caregiver unable to perform.” The POC contained an order for “SN to identify and intervene to eliminate or reduce complications and to notify the physician of any abnormal findings.” Further review of the POC revealed no blood sugar parameters for notification of the physician by the Agency’s nurse, and no order on the frequency of the blood sugar checks or who was to perform the blood sugar checks. The POC also did not contain bleeding precautions under “safety measures” or an order for the nurse to assess, monitor or notify the physician for abnormal bleeding or bruising. Record review of discharged Patient 2 revealed a Nursing Clinical Progress Note dated 8/11/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented patient’s blood sugar of “132” but did not document who performed the blood sugar check. The visit note read “Insulin administration performed by Patient.” Record review of discharged Patient 2 revealed a Nursing Clinical Progress Note dated 8/14/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented patient’s blood sugar of “121” but did not document who performed the blood sugar check. The visit note read “Insulin administration performed by Patient.” Record review of discharged Patient 2 revealed a Nursing Clinical Progress Note dated 8/21/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented patient’s blood sugar of “140” but did not document who performed the blood sugar check. The visit note read “Insulin administration performed by Patient.” Record review of discharged Patient 2 revealed a Nursing Clinical Progress Note dated 8/25/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented patient’s blood sugar of “118” but did not document who performed the blood sugar check. The visit note read “Insulin administration performed by Patient.” Record review of discharged Patient 2 revealed a Nursing Clinical Progress Note dated 9/01/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented patient’s blood sugar of “121” but did not document who performed the blood sugar check. The visit note read “Insulin administration performed by Patient and Caregiver.” Record review of discharged Patient 3 in the Agency’s EMR system revealed a start of care date of 6/19/2025 and a discharged date of 8/06/2025. Records contained a Home Health Certification and Plan of Care for period 6/19/2025 to 08/06/2025 signed by the Adm/DON/Agency Owner. The POC contained a primary diagnosis of “Type 2 Diabetes Mellitus with Ketoacidosis (life-threatening complication of diabetes where the body lacks enough insulin to use blood sugar for energy) without Coma (deep unconsciousness or unresponsive state)” and a nurse frequency of once a week for week 1, then twice a week for 2 weeks, then once a week for 7 weeks. The POC contained the medication Sitagliptin (medication used alongside diet and exercise to lower blood sugar) 100mg one tablet daily. The POC contained orders for “SN to assess diabetic status, identify signs and symptoms of impaired diabetic function and diabetic management,” skilled nurse to instruct patient/caregiver on inspection and care to the patient’s feet, and “SN to perform inspection of patient’s feet.” Further review of the POC revealed no blood sugar parameters for notification of the physician by the Agency’s nurse, and no order on the frequency of the blood sugar fingerstick checks or who was to perform the blood sugar fingerstick checks . Record review of discharged Patient 3 revealed a Nursing Clinical Progress Note dated 6/24/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “Fingerstick performed by SN using aseptic (without germs) technique” and blood sugar “142.” Record review of discharged Patient 4 in the Agency’s EMR system revealed a start of care date of 9/18/2025 and a discharged date of 9/24/2025. Records contained a Start of Care OASIS comprehensive assessment dated 9/18/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented that the patient had a history of “End Stage Renal Disease (condition in which the kidneys can no longer filter waste and excess fluids) on hemodialysis (procedure in which a machine with a specialized filter continuously pumps blood out of the body to filter out waste and excess fluid before returning the cleaned blood to the body). The Adm/DON/Agency Owner check marked the boxes “AV Graft (a surgically implanted tube that connects an artery to a vein) /Fistula (a surgical connection of an artery to a vein used to strengthen a vein for hemodialysis access by increasing blood flow and pressure in the vein),” and assessed “Bruit (whooshing sound created by turbulent blood flow and the connection of an artery to a vein)” and ‘Thrill (vibration created by turbulent blood flow and the connection of an artery to a vein)” within the Dialysis (medical treatment to filter out waste and excess fluid from the body) section of the assessment. The Adm/DON/Agency Owner documented “Patient’s dialysis access site was inspected for signs of infection or complications.” Record review of discharged Patient 4 revealed a Home Health Certification and Plan of Care for period 9/18/2025 to 9/24/2025 signed by the Adm/DON/Agency Owner. The POC contained a primary diagnosis of “Unspecified Systolic Congestive Heart Failure (condition when the hearts main pumping chamber weakens and cannot squeeze and pump blood effectively to the rest of the body, causing blood to back up and fluid to build up in the lungs and body),” a secondary diagnosis of End Stage Renal Disease, and a nurse visit frequency of twice a week for two weeks, then once a week for 7 weeks. Further review of the entire POC revealed no orders for the assessment of the dialysis access site. Record review of discharged Patient 4 revealed a Nursing Clinical Progress Note dated 9/19/2025 signed by the Adm/DON/Agency Owner. The progress note revealed no documentation that the dialysis access site was assessed. Record review of discharged Patient 4 revealed a Nursing Clinical Progress Note dated 9/22/2025 signed by the Adm/DON/Agency Owner. The progress note revealed no documentation that the dialysis access site was assessed. The Adm/DON/Agency Owner documented “evaluate dialysis access” under “Plan for next visit.” Record review of discharged Patient 4 revealed a Nursing Clinical Progress Note dated 9/24/2025 signed by the Adm/DON/Agency Owner. The progress note revealed no documentation that the dialysis access site was assessed. The Adm/DON/Agency Owner documented “evaluate dialysis access” under “Plan for next visit.” Record review of discharged Patient 4 revealed a Transfer Inpatient Facility Discharge and Discharge Summary dated 9/24/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented that the patient was hospitalized for “worsening of systems…increased shortness of breath, fatigue, and decreased tolerance to activity despite adherence to home medications and dialysis schedule.” Record review of discharged Patient 6 in the Agency’s EMR system revealed a start of care date of 10/24/2025 and a discharged date of 12/22/2025. Records contained a Start of Care OASIS comprehensive assessment dated 10/24/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented a primary diagnosis of “Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar).” The Adm/DON/Agency Owner documented skill nursing was “necessary to monitor blood glucose (sugar)” and nursing interventions will include “blood glucose levels.” Record review of discharged Patient 6 revealed a Home Health Certification and Plan of Care for period 10/24/2025 to 12/22/2025 signed by the Adm/DON/Agency Owner. The POC contained a primary diagnosis of “Type 2 Diabetes Mellitus with Hyperglycemia” with a nurse visit frequency of once a week for the first week, then twice a week for one week, then once a week for 6 weeks. The POC contained the medications Glyburide (medication used alongside diet and exercise to lower blood sugar) 5mg 1 tablet twice daily, and Metformin (medication to lower blood sugar) 500mg 1 tablet twice daily. The POC contained orders for “SN to assess diabetic status, identify signs and symptoms of impaired diabetic function and diabetic management,” and “SN to instruct patient/caregiver on diabetic management…proper use of glucometer (device to check blood sugar);logging of blood sugar results…and reporting to SN/Physician.” Further review of the POC revealed no blood sugar parameters for notification of the physician by the Agency nurse, and no order on the frequency of the blood sugar fingerstick checks or who was to perform the blood sugar fingerstick checks . Record review of discharged Patient 6 revealed a Nursing Clinical Progress Note dated 10/28/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “Fingerstick performed by SN using aseptic (without germs) technique” and blood sugar “134.” Record review of discharged Patient 6 revealed a Nursing Clinical Progress Note dated 10/30/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “Fingerstick performed by SN using aseptic (without germs) technique” and blood sugar “134.” Record review of discharged Patient 6 revealed a Nursing Clinical Progress Note dated 11/05/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “Fingerstick performed by SN using aseptic (without germs) technique” and blood sugar “148.” Record review of discharged Patient 6 revealed a Nursing Clinical Progress Note dated 11/12/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “Fingerstick performed by SN using aseptic (without germs) technique” and blood sugar “149.” Record review of discharged Patient 6 revealed a Nursing Clinical Progress Note dated 12/11/2025 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “Fingerstick performed by SN using aseptic (without germs) technique” and blood sugar “124.” Record review of discharged Patient 7 revealed a start of care date of 6/12/2025 and a recertification “Home Health Certification and Plan of Care” for period 10/10/2025 to 12/08/2025 signed by the Adm/DON/Agency Owner on 10/06/2025. The POC contained a primary diagnosis of “ Hypertensive Heart Disease (thickening of the heart muscle due to high blood pressure) with Heart Failure (heart not pumping blood as it should to meet the body’s needs), secondary diagnosis of narrowing arteries in the left leg caused by plaque (sticky substance that builds up on surfaces of the body), and a nurse visit frequency of twice a week for week one with 2 as needed visits. The POC contained the medication Apixaban (blood thinning medication to treat blood clots) 5mg 1 tablet twice a day. The POC did not contain bleeding precautions under “safety measures” or an order for the nurse to assess, monitor or notify the physician for abnormal bleeding or bruising. An interview was conducted with the Adm/DON/Agency Owner on 6/05/2026 at 5:32pm. When asked about the Agency's policy on what should be included in the Plan of Care. The Adm/DON/Agency Owner stated, “The diagnosis of the patient, the face-to-face notes, orders from the doctor plus my own assessment (of the patient) to include an account of care for the doctor to review.” When asked ‘What should be included in the POC for a dialysis patient?” The Adm/DON/Agency Owner stated, “check for weakness, ESRD, weight checks” and assess the dialysis access site for “bruit (whooshing sound) and thrill (vibration).” The Adm/DON/Agency Owner stated “I think it's (assessment of the dialysis access site) in the plan of care. There’s an intervention (for the assessment of the Dialysis access site) that is included in the body systems that says genitourinary (Two body systems with one responsible for creating and transporting urine out of the body and the other responsible for reproduction).” The Surveyor shared the findings for Patient 4. When asked why the POC did not contain an assessment of the patient’s dialysis access site. The Adm/DON/Agency Owner stated, “I don't know why it (EMR system) didn't transcribe it (intervention for assessment of the dialysis site on the POC). There's an intervention that stated that (assess dialysis access site).” When asked about the nursing visits dated 9/19/2025, 9/22/2025, and 9/24/2025 and the missing assessment of the Patient 4’s dialysis access site. The Adm/DON/Agency Owner stated, “Maybe it (missing assessment of the dialysis site) was a typo (unintentional mistake made while typing) or oversite.” In a continued interview with the Adm/DON/Agency Owner the Surveyor shared the findings of the missing blood sugar parameters for notification of the physician by the Agency’s nurse and missing orders for the blood sugar fingerstick checks on the POC for Patients 2, 3 and 6. The Adm/DON/Agency Owner stated “There's an intervention in there (the POC) that says all that (check/monitor blood sugars and notify the physician for out-of-range blood sugars) and then during the (patients) visits the (blood sugar) parameters comes up in the skilled visits. The parameters should be there (in the POC).“ The Adm/DON/Agency Owner stated she had issues with the EMR system and interventions she added to the POC for the patients were omitted by the system. The Adm/DON/Agency Owner stated, “I know when to contact the physicians when it's (the patients’ blood sugars) are too high or too low. I’ll keep an eye out now for the parameters (on the POC).” When asked about the missing orders for the Skilled Nurse to perform a fingerstick to check the patient’s blood sugar on Patients 3 and 6. The Adm/DON/Agency Owner stated “I thought that there was an intervention in the Plan of Care which is generic and said check blood sugar and log it every visit. I don’t know why it did not show up.” The Adm/DON/Agency Owner stated “Usually the patients do it (finger sticks to check their blood sugar). They (the patients) have their own machines so when I go to their home I assist them. Sometimes it's (blood sugar checks) are not in the doctor's orders or in the face to face (visit from the doctor).” The Adm/DON/Agency Owner stated the patients were educated on how to perform finger sticks to check their blood sugars during the nursing visits and “I included that (skilled nurse performed finger stick) in there (visit note) so the doctor can see” that the patient was educated on how to check their blood sugar. Further interview at the same time with the Adm/DON/Agency Owner, the Surveyor asked what should be on the POC for patients on blood thinning medications such as Apixaban. The Adm/DON/Agency Owner stated that the nurse should assess the patients’ “skin and make sure they (the patients) are not bruising.” The Surveyor shared the findings of the missing bleeding/anticoagulant (blood thinner) precautions under the safety measures, and missing orders for the nurse to assess, monitor or notify the physician for abnormal bleeding or bruising on Patients 2 and 7. The Adm/DON/Agency Owner stated “I think this (bleeding/anticoagulant precautions) should be on the plan of care. When we (the Agency) get a face-to-face order the doctor is telling us (the nurses) what to do. Maybe the doctor did not specify that (patient’s risk for bleeding) on the face to face (order). It's good (for the nurse) to act (address the patient’s risk of bleeding) as well. We (the Agency) don't necessarily have an order from the doctor that says we need it (risk for bleeding) transferred onto that (the Plan of Care).” When asked about the potential patient outcome for not including all required items on the Plan of Care. The Adm/DON/Agency Owner stated that the nurse “can miss a lot of things (treatments, interventions, and patient education) to do for the patient, because the Plan of Care is a guide” for the patient’s care. Review of the Agency’s undated “Care Planning Process” policy read in part “The Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and/or needs… Each patient/client must receive an individualized POC, including any revisions or additions. The individualized POC must specify the care and services necessary to meet the patient/client 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 POC… The POC, which includes the following plan of care elements, is developed in consultation with staff, client, physician and other providers involved in the client's care and will serve as the initial plan of care: All pertinent clients diagnosis/problems… Safety measures to protect against injury… a description of the patient/clients risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors… Specific procedures/treatments to be performed… Patient specific interventions and education, measurable outcomes and goals identified by the HHA and the patient... Other appropriate items such as precautions and contraindications… Any additional items the HHA or physician and or non-physician practitioner may choose to include.”

A recertification survey was conducted on 05/26/2023. The census was 5 Licensed and Certified patients. An exit conference was conducted on 6/13/2023.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain an emergency preparedness plan that was reviewed and revised every 2 years and was based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach for 3 (2020, 2021, and 2022) of three years reviewed during the survey. The failure placed the agency staff and patients subject to poor outcomes during an actual emergency. The surveyor requested the Emergency preparedness plan documents for the last three years during the opening conference on May 26,2023. On 06/09/2023 at 2:00 PM the surveyor reviewed a three-ring binder provided by the Administrator on 06/09/2023. There were no reviews or revisions of the plan for 2020, 2021, and 2022. The binder contained a risk assessment plan dated 01/31/10 and documented the risk from epidemic as “None.” Review of the entire binder failed to find a more current risk assessment. The binder contained emergency preparedness policy and plan dated 080111. An interview was conducted with the Administrator / Disaster Coordinator on 06/13/23 at 12:59 PM. The surveyor shared the findings of the review of the emergency preparedness plan and risk assessment documents provided. The Administrator clarified the correct Emergency preparedness policy and response plan in the policy manual provided and was dated 01/29/2020. The Administrator stated “the previous owner went over (the emergency preparedness program) with me in February 2022, and I have not done anything with it since 2022.” The surveyor asked if the Administrator had any additional emergency preparedness documents to provide for review and the Administrator stated: “No.” Agency policy titled 7.8 Emergency Preparedness and Response Plan read in part: “The agency will develop, maintain, and implement a written Emergency preparedness and Response Plan (Plan), based on the Agency’s risk assessment. It establishes a plan of action for providing continuous patient care and continuous business operations in the event of a disaster.”

A recertification survey was conducted on 05/26/2023. The census was 5 Licensed and Certified patients. An exit conference was conducted on 6/13/2023. Abbreviations: BM- Bowel Movement CMS – Centers for Medicare and Medicaid Services COVID-19 – Coronavirus disease of 2019 DADS – Department of Aging and Disability now known as Health and Human Services EMR – Electronic Medical Record DON – Director of Nurses HHA- Home Health Agency SN – Skilled Nurse ED – Emergency Department Q- Every QAPI – Quality Assessment Performance Improvement NAR / EMR – Nurse Aide Registry and Employee Misconduct Registry PT - Physical Therapist or Physical Therapy HHSC- Health and Human Services Commission

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patients’ right for 2 (Patients 1 and 3) of 3 patients to be advised of the contact information for the following Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The failure placed patients at risk of missing out on resources in the area that might assist them in maintaining their health and well- being. Review of the sample patient admission folder prepared by and provided by the Administrator on 06/01/23 at 10:00 AM revealed no information for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. During a home visit on 06/05/23 at 1:15 PM with Patient 1 the surveyor observed the home folder provided by the agency. The folder contained no information on the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center near Dallas, TX where Patient 1 resided. The surveyor asked Patient 1’s family member if any information had been removed from the home folder. Patient 1’s family member stated nothing was removed from the folder. During a home visit on 06/05/23 at 3:15 PM with Patient 3 the surveyor observed the home folder provided by the agency. The folder contained no information on the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center near Dallas, TX where Patient 3 resided. The surveyor asked Patient 3’s family member if any information had been removed from the home folder. Patient 3’s family member stated they were not aware of anything being removed from the folder. During an interview with the Administrator/DON on 06/13/2023 at 1:38 pm the surveyor reviewed the findings of the review of the sample admission folders provided by the Administrator / DON and reviewed on 06/01/23, the Patient 1 and 3 folders reviewed during the home visits on 06/05/23. No resource lists were found in Patient 1 and Patient 3’s home folders, or in the sample admission folder provided. The Administrator reviewed the sample folder provided and looked for a second folder which contained a resource list with the required resources. The surveyor asked about this folder and the lack of a list of resources in Patient 1 and 3’s home folders? The Administrator stated: “It was an oversight.” A review of the agency policy titled “3.1 Patient Bill of Rights and Responsibilities Rights …” read in part: The patient and representative, if any, have the right to be informed of the patient’s rights in a language and manner the individual can understand. The Agency must protect and promote the exercise of these rights… Agency staff will be responsible for knowing, observing, and implementing the patient’s rights … The Patient Bill of Rights and responsibilities will be give to the patient at the time of the patient’s assessment and prior to admission to the Agency… The Patient Bill of Rights must include, but not be limited to: …To be advised of the names, addresses, and telephone numbers of pertinent, federally funded and State-funded State and local consumer information, consumer protection, and advocacy agencies...”

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 record review and interview the agency failed to document both the existence of a complaint and the resolution of the complaint for 2 (Patient 1 and 4) of 2 complaints about PT and nursing services. This failure places patients at risk of receiving poor quality services and violations of their rights when the agency failed to document, investigate, and resolve complaints. The surveyor requested the complaint log documentation for the previous three years during the opening conference on 5/26/20233 at 1:40 PM. The surveyor reviewed the three- ring binder titled “Complaint Log” provided by the Administrator on 06/09/2023. The surveyor noted one complaint dated 03/15/22 regarding nursing services for Patient #4. The was complaint documented by the Alternate DON and stated the complaint was about the nurse arriving last for a visit, and dates were blank after sections titled: “Action Taken” and “Resolution/Follow-Up.” There were no other complaints documented in the Complaint Log. The surveyor reviewed the QAPI information provided by the agency on 06/09/2023 and found no information about complaints in the QAPI information provided for 2020, 2021, 2022, and 2023. Review of Patient #1’s clinical record revealed PT A provided services in October 2022. Patient 1’s clinical record revealed PT services currently being provided by PT B. There was no documentation of a complaint in Patient 1’s clinical record. An interview was conducted with the family member (and with the assistance of a Spanish interpreter employed by HHS) for Patient 1 on 06/09/23 at 3:02 PM. The surveyor asked the family member about the nursing and PT services Patient 1 received from the agency. The family member stated the Patient and family did not like the first PT that had provided PT services, and they do like the PT they have now. The surveyor asked if they reported this to the agency and the family member stated they did report this to the Administrator / Supervising Nurse and they had assigned a different PT. On 06/13/23 at 12:59 PM the surveyor conducted an interview with the Administrator. The surveyor asked about the PT services for Patient #1. The Administrator stated: At the start of care, I used Contract Therapy provider AA and “he was harsh on Patient 1, and the family asked to change therapists.” The surveyor asked what the Administrator did in response to the family member’s report about the therapist. The Administrator stated they talked to PT A who said he “did what we are we there for”. The Administrator stated they told PT A they understood PT A wanting to push Patient 1, and that the Administrator also felt PT A was not supporting the patient’s rights to refuse care. The Administrator stated when PT was ordered again for Patient 1 “I changed to a different PT contractor.“ The surveyor shared the results of the review of the Agency QAPI program and complaint log information provided and asked about the lack of dates for actions taken and resolution for the March 15, 2022 complaint. The Administrator stated the bottom of the form was signed. The surveyor shared the findings of no complaint found about the PT services for Client 1 in the complaint log. The Administrator reviewed the complaint log and stated they didn’t find it. The Administrator stated: “I have a folder in my car which is filing, and it may be there.” The surveyor asked if the complaint was received in October 2022 when PT A was assigned to provide services for Client 1. The Administrator stated: “Yes.” The surveyor offered the opportunity for the agency to provide additional documentation prior to the exit conference and no additional information or documentation was provided. Agency policy titled: “3.1 Patient Bill of Rights and Responsibilities” dated 01/29/2020 read in part: “The Agency must protect and promote the exercise of these rights…Agency staff will be responsible for knowing, observing, and implementing the patient’s rights… The Patient Bill of Rights must include, but not be limited to: … To voice grievances regarding treatment or care that is or fails to be furnished… Any HHA staff whether employed directly or under arrangements in the normal course of providing services to patients, who identifies, notices or recognizes incidences or these circumstances must report this to the HHA and the Agency must investigate complaints made by the patient/ the patient’s representative/ and the patient’s caregiver / and family regarding treatment or care that is (or fails to be furnished … by anyone furnishing services on behalf of the Agency and must document the existence of the complaint and the resolution of the complaint. Take action to prevent further potential violations while the complaint is being investigated… Agency policy titled: “9.1 Quality Assessment Performance Improvement Plan” dated 01/29/2020 read in part: “The Agency will develop, implement and maintain and (sic) effective, ongoing HHA-wide, data-driven Quality Assessment Performance Improvement Plan (QAPI) program. The Agency’s governing body will ensure that the program reflects the complexity of its organization and services; involves all Agency services (including those services provided under contract … Areas for improvement will be identified through the collection of data for analysis of Agency services. Systems of measure include: a. Agency derived documentation (including): …Patient complaints and satisfaction survey data, including agency response to complaints…”

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, record review, and interview the comprehensive assessment for 2 (Patient 3 and 5) of 2 patients reviewed who had a dialysis access failed to accurately reflect the patient's condition, including the location and status of the dialysis access site. Patients were at risk of patency issues, infection, and bleeding related to the dialysis access site. Review of Patient 3’s record revealed no assessment of the dialysis access location or type of access for comprehensive assessments dated 02/24/2023, 04/17/2023, and 04/26/2023. Review of Patient 3’s plan of care for the certification 02/28/23 to 04/28/23 revealed a diagnosis of end stage renal disease (complete kidney failure) and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the dialysis access site (a surgical procedure to join and vein and artery to allow for higher pressure and faster blood flow to allow for hemodialysis.) During a home visit on 06/05/2023 at 3:15 PM the surveyor observed the Administrator / DON provide the weekly nursing visit. The surveyor observed the entire visit and noted the nurse did not assess the dialysis access site, and did not ask the patient or the family member about the dialysis access site. An interview was conducted on 06/08/23 at 3:32 PM with the Administrator / DON. The surveyor reviewed the plan of care, assessment, and observation visit findings for Patient 3 with the Administrator/DON. The surveyor asked why there were no orders to assess the dialysis access site, The Administrator / DON stated: “There is no place for it in (the electronic medical record). I should have done paper charts, I would have done better.” The surveyor asked why the nurses notes and assessments contained no evidence of assessment of the patient’s dialysis access site, and why the nurse didn’t assess the dialysis access site during the home visit made with the surveyor. The Administrator / DON stated: “I look but I don’t assess it (the dialysis access site), because I am not the provider for dialysis. How would I assess, what is the reason, I haven’t had any complaints, and I haven’t looked.” Review of Patient 5’s record revealed no assessment of the dialysis access location or type of access for comprehensive assessments dated, 06/02/2022, 07/24/202, and 08/12/2022. Review of Patient 5’s plan of care for the certifications 06/06/2022 to 08/04/2022 revealed a diagnosis of end stage renal disease (complete kidney failure). The POC had orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the dialysis access site. An interview was conducted on 06/08/23 at 4:43 PM with the Administrator / DON. The surveyor reviewed the plan of care findings for Patient 5 and asked why there were no orders to assess the dialysis access site, and why the assessments contained no evidence of assessment of the Patient 5’s dialysis access site. The Administrator/ DON reviewed the record and stated: “I think it is something I have to type it in [into the electronic medical record note]. The Administrator stated: “I told you, at that time, I was getting my hands on the electronic medical record, and that is why.” The surveyor asked if the Administrator was learning to use the electronic medical record at the time of this documentation. The Administrator stated that was correct. Review of agency policy and procedures titled: 4.2 Patient Assessment Guidelines with a revision date of 01/29/2020 read in part: The Agency will utilize and adhere to a defined comprehensive assessment in order to identify the patient’s needs for home care and that meets the patient’s medical, nursing, rehabilitative, social and discharge planning needs. Review of agency policy and procedures titled: 8.8 Client Records Content with a revision date of 01/29/2020 read in part: The Agency must maintain a clinical record containing past and current information for every client 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… Review of the Lippicott Procedures – Hemodialysis access care, home care dated 5/5/21 revealed in part “…Inspect the AV access extremity and compare it with the other extremity, noting any obvious differences, assess the AV access extremity for swelling, redness, warmth, drainage from prior needle sites, ecchymosis (black and blue areas), …Auscultate for the presence of a bruit (whooshing sound (blood flow) and palpate (touch) the AV access for a continuous sensation, known as a “thrill” (pulse) (patency)…Document all assessments including…as well as your assessment of the AV access extremity and AV access site. Make sure to document the presence or absence of a bruit and thrill…

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the Plan of care for 6 (Patients 1,2,3,4,5 and 6) of 7 patients contained all required items: Patient 3 and 5 all necessary interventions to address the underlying risk factors of the dialysis access site. Patient 1, 2 and 4 interventions to address the diabetes primary diagnosis, and a statement of risks for hospitalization and emergency room visits. Patient 6 a statement of risks for hospitalization, all pertinent diagnoses, and all medications. Failure to have a complete plans of care affected the care provided by the agency staff and had the potential to affect client health outcomes. Review of Patient 3’s plan of care for the certification 02/28/23 to 04/28/23 revealed a diagnosis of end stage renal disease (complete kidney failure) and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the dialysis access site (a surgical procedure to join and vein and artery to allow for higher pressure and faster blood flow to allow for hemodialysis.) Review of the nursing notes dated 03/01/23, 03/06/23, 03/13/23, 03/20/23, 03/27/23, and 04/05/23 revealed no assessment of the Patient’s dialysis access site. During a home visit on 06/05/2023 at 3:15 PM the surveyor observed the Administrator / DON provide the weekly nursing visit. The surveyor observed the entire visit and noted the nurse did not assess the dialysis access site, and did not ask the patient or the family member about the dialysis access site. An interview was conducted on 06/08/23 at 3:32 PM with the Administrator / DON. The surveyor reviewed the plan of care findings for Patient #3 and asked why there were no orders to assess the dialysis access site, The Administrator / DON stated: “There is no place for it in (the electronic medical record). I should have done paper charts, I would have done better.” The surveyor asked why the nurses notes contained no evidence of assessment of the patient’s dialysis access site. The Administrator / DON stated: “I look but I don’t assess it, because I am not the provider for dialysis. How would I assess, what is the reason, I haven’t had any complaints, and I haven’t looked.” Review of Patient 5’s plan of care for the certifications 06/06/2022 to 08/04/2022 revealed a diagnosis of end stage renal disease (complete kidney failure). The POC had orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the dialysis access site. Review of the nursing notes dated 06/07/22, 06/14/22, 07/05/22, 07/12/22, 07/18/2022, 07/19/22, and 07/26/2022 revealed no assessment of Patient #5’s dialysis access site. An interview was conducted on 06/08/23 at 4:43 PM with the Administrator / DON. The surveyor reviewed the plan of care findings for Patient #5 and asked why there were no orders to assess the dialysis access site, and why the nurses’ notes from June and July 2022 contained no evidence of assessment of the Patient 5’s dialysis access site. The Administrator/ DON reviewed the record and stated: “I think it is something I have to type it in [into the electronic medical record note]. The Administrator stated: “I told you, at that time, I was getting my hands on the electronic medical record, and that is why.” The surveyor asked if the Administrator was learning to use the electronic medical record at the time of this documentation. The Administrator stated that was correct. Review of Patient 1’s plan of care for the certification 02/14/23 to 04/14/23 revealed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Cataract (blood sugar metabolism disorder and clouding of the lens of the eye), and Alzheimer’s (dementia) and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the patient’s blood sugars during nursing visits. The POC failed to include a statement of risks for hospitalization and emergency room visits. Review of the nursing notes dated 02/15/23, 02/22/23, 03/01/23, 03/08/23, 03/15/23, 03/21/23, 03/28/23, and 04/05/23 revealed no assessment of the Patient’s blood sugars. During a home visit on 06/05/2023 at 1:15 PM the surveyor observed the Administrator / DON provide the weekly nursing visit with Patient #1. The surveyor observed the entire visit and noted the nurse did not check the blood sugar of Patient #1 or ask the family member about the patient’s blood sugar results. The surveyor asked the family member if they were checking the patient’s blood sugars near the end of the visit, and the family member showed the surveyor a log that ended in December 2022 and stated they were not checking the patient’s blood sugars since the patient came home from the hospital in December of 2022[HC(1] . An interview was conducted on 06/08/23 at 3:15 PM with the Administrator / DON. The surveyor reviewed the plan of care and visit note findings for Patient # 1 and asked why there were no orders for the nurse to check the blood sugar, no statement of risks for hospitalization and emergency room visits, and why the nurses’ notes from February and March 2023 contained no evidence of assessment of the patient’s blood sugars. The Administrator/ DON reviewed the record and stated she did not see orders to check the blood sugars on the POC. The Administrator / DON stated that “my downfall is the electronic medical record” The Administrator stated they did not know where to enter the risks for hospitalization and emergency room visits in the electronic medical record. The Administrator stated: “Even if I know what to do, I don’t know how to transcribe it.” Review of Patient 2’s plan of care for the certification 02/14/23 to 04/14/23 revealed a primary diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia[HC(2] and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the patient’s blood sugars during nursing visits. The POC failed to include a statement of risks for hospitalization and emergency room visits. Review of the nursing notes dated 04/19/23 and 05/09/23 revealed the nurse documented teaching about insulin during the visits. The Plan of care did not contain insulin in the medication list. During a home visit on 06/05/2023 at 2:15 PM the surveyor observed the Administrator / DON provide the weekly nursing visit for Patient #2. The surveyor observed the entire visit and noted the nurse did not check the blood sugar of Patient #2 and did not ask to see the blood sugar results on the glucometer. The surveyor asked Patient 2 if they would retrieve the patient’s glucometer so the surveyor could review the history of blood sugars at the end of the visit. Patient 2 brought the glucometer to the nurse and the surveyor. The Administrator / DON then reviewed the history on the glucometer and briefly turned it toward the surveyor and stated it indicated a blood sugar of 156. The surveyor asked if the patient was on insulin. The patient stated they were not on insulin, and the nurse asked the patient if they were still taking garlic for their blood sugar, and Patient 2 stated they did take garlic today and their other medications. An interview was conducted on 06/08/23 at 3:00 PM with the Administrator / DON. The surveyor reviewed the plan of care and visit note findings for Patient #2 and asked why there were no orders for the nurse to check the blood sugar and no statement of risks for hospitalization and emergency room visits. The Administrator/ DON reviewed the record and stated she did not see orders to check the blood sugars on the POC. The nurse stated that was the main thing they were working on for Patient #2 and the orders should be on the POC. The surveyor asked about the lack of statement of risks for hospitalization and emergency room visits. The Administrator / DON stated: “I don’t know where it is supposed to be.” The surveyor asked if the Administrator / DON meant where to put it in the electronic medical record. The Administrator / DON stated “Yes.” The surveyor asked if the patient was on insulin, and about the nurses’ notes dated 04/19/23 and 05/09/23 that documented that the Administrator / DON taught insulin. The Administrator / DON stated Patient 2 “never had it (Insulin), and I have never taught it. Why is it on the note? I think it is a typo. I am surprised, maybe I was sleeping.” The nurse stated: “Every time (I visit) she (Patient 2) has a big box and I show her how to do it (check the blood sugar), and she (Patient 2) does it for me. Because she (Patient 2) told me what the sugar was (on the visit made with the surveyor on 06/05/2023, I didn’t ask to see her machine.” Review of Patient 4’s plan of care for the certification 02/07/23 to 04/07/23 revealed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy (blood sugar metabolism disorder and nerve damage to the feet) and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the patient’s blood sugars during nursing visits, no other orders for care of the client with Diabetes and Neuropathy. The POC also failed to include a statement of risks for hospitalization and emergency room visits. Review of the nursing notes dated 02/10/23, 02/15/23, 02/22/23, 03/08/23, 03/14/23, and 03/28/23, revealed the same narrative on each of the notes as follows: “SN met patient at home and checked all vital signs. Patient states she has a death in the family and she is worried. SN discussed stress management with patient and did medication reconciliation. SN checked blood sugar and it was 156. Patient just ate noodles and blood sugar is a little elevated. Patient states, she was having some headaches yesterday, but she stated she feels well today.” An interview was conducted on 06/08/23 at 4:32 PM with the Administrator / DON. The surveyor reviewed the plan of care and visit note findings for Patient #4 and asked why there were no orders for the nurse to check the blood sugar, no orders for care of the client with Diabetes and Neuropathy, and no statement of risks for hospitalization and emergency room visits. The Administrator/ DON reviewed the record and stated she did not see orders to check the blood sugars on the POC. The Administrator / DON stated: “There are no orders for finger stick Q (every) visit. It is not available in (the electronic medical record) as a choice. “Someone told me we don’t do the finger sticks for every patient. We don’t use our own machine, and we don’t know if people (patients) will do them. We teach the caregivers, that is probably why it isn’t on the plan of care.” The surveyor asked why the narrative notes are the same on the visit notes. The Administrator / DON stated: “You can pull (the notes) forward if nothing has happened, and you have to change your narrative. So, I just pulled them forward and forgot to change my narrative.” Review of Patient 6’s plan of care for the certification 02/22/23 to 04/22/23 revealed a primary diagnosis of Essential Hypertension (high blood pressure), Atrial Fibrillation (rapid and irregular heart rate), and Anemia (low iron in the blood cells), Review of the entire Plan of Care failed to find a diagnosis of Constipation. Review of the entire plan of care revealed no statement of risks for hospitalization, orders for care of constipation, and medications to treat Constipation. Nurses’ notes dated 02/23/2023, 03/08/2023, 03/21/23 in the visit narrative section read: “Patient states, she is having constipations because she stated she has not had a BM in 3 days. SN advised patient to take fiber and drink water to give her free bowel…. SN advised patient about over the counter stool softeners if natural remedies does not work. Patient also c/o pain in the left upper abdominal quadrant. Patient states, she layed (sic) down for a while and the pain went away.” An interview was conducted on 06/08/23 at 1:21 PM with the Administrator / DON. The surveyor reviewed the plan of care and visit note findings for Patient #6. The surveyor asked about the recommendations for treatment in the notes. The Administrator / DON stated it is regular (nutrition requirements) on the POC. “I was talking about fiber from previous notes and it just copied forward on the other notes.” The surveyor asked why the diagnosis, medications, and treatment recommendations were not on the POC. The Administrator / DON stated: “The doctor never gave orders, she has liver issues, polys in liver and the doctor knows (about the constipation).” The Administrator / DON stated: “After three days it resolved. Maybe she has over the counter stool softeners?.” The surveyor asked why those were not included in the medications listed on the POC. The Administrator / DON reviewed medications listed on the POC and stated: “she doesn’t have it in there, no medications on the POC and no diet issues, no dx no medications, nothing on the POC, just home remedies, the doctor is very careful, for it not being on the POC, it is not on the POC.“ The surveyor asked why the POC failed to contain the required statement of risks for hospitalization and ER visits. The Administrator /DON reviewed the POC and stated: “I am trying to find out where to put it. Do you know what heading in the (electronic medical record) it is, so I can find it?” The Administrator / DON stated: “The reason is I don’t find it is I don’t see where to put it in the recert (recertification).” Agency policy titled: 4.4 Patient Reassessment dated 01/29/2020 read in part: Each patient must receive the home health services that are written in an individualized plan of care …The individualized plan of care must include the following: All pertinent diagnoses, … all medications and treatments… A description of the patient’s risk for emergency department visits and hospital re-admission, all necessary interventions to address the underlying risk factors. Patient-specific interventions and education; … All patient care orders, including verbal orders, must be recorded in the plan of care… Agency policy titled: 5.7 Care Planning Process dated 01/29/2020 read in part: The Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and / or needs…. Each patient/client must receive an individualized POC, including any revisions or additions. The individualized POC must specify the care and services necessary to meet the patient/client needs as identified in the comprehensive assessment…

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agencies governing body failed to be responsible for ensuring that an ongoing program for quality improvement and patient safety was implemented, and maintained for 3 (2020, 2021, and 2022) of 3 years of the survey review period. This failure placed the agency patients were at risk of poor quality of care and patient safety was at risk when the agency’s practices were not evaluated. The surveyor requested the QAPI plan and documents for the previous three years during the entrance conference on 05/26/2023. The Administrator provided a three-ring binder with QAPI documents on 06/09/2023 at 1:16PM. The surveyor reviewed the QAPI plan which dated the key focus indicators for 2014, and included an annual evaluation dated 2010. There were no reports, indicators, audits, or evaluations for 2020, 2021, or 2022. An interview was conducted with the Administrator on 06/13/2023 at 2:30 PM. The surveyor shared the findings of the review of the QAPI documents provided. The surveyor asked if the policy 9.1 titled Quality Assessment Performance Improvement Plan with a revision date of 01/29/2020 found in the policy and procedures manual provided was the correct plan. The Administrator stated: “Yes.” The surveyor asked about the lack of current QAPI documents. The Administrator stated the previous owner had gone over plan with the Administrator in February 2022, and the Administrator stated they had not done any QAPI activities since that review. The surveyor asked why the Agency had not implemented the plan policies for 2020, 2021, 2022, and 2023 and the Administrator stated: “because I have a lot of things going on, lots of paperwork, the visits, and I was hoping to grow a little to hire staff.” The Administrator stated: “My sister (the Alternate Administrator) is a Family Nurse Practitioner and is going to move here, and we will be in better shape. We don’t have enough to hire help.” Agency policy titled 9.1 Quality Assessment Performance Improvement Plan read in part: “The Agency will develop, implement and maintain and (sic) effective, ongoing HHA-wide, data-driven Quality Assessment Performance Improvement Plan (QAPI) program. The Agency’s governing body will ensure that the program reflects the complexity of its organization and services; involves all Agency services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergency are services, hospital admissions and re-admission; and takes actions that address the Agency’s performance across the spectrum of care; including the prevention and reduction of medical errors. The Agency will maintain documentary evidence of the QAPI program and will be able to demonstrator the program operation to CMS…”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program for 3 (June of 2020, 2021, 2022, to June 13, 2023) of 3 years of the survey review period. This failure places the patients and staff subject to harm from potential infections when the agency failed to document infections, track patterns and trends of infections and establish and implement corrective plans of action to mitigate risks of infections. The surveyor requested the Infection Control and QAPI documents for the last three years during the opening conference on May 26, 2023. The surveyor reviewed a three-ring binder provided by the Administrator on 06/09/2023 at 2:15 PM. The binder contained no evidence of tracking of any infections, no infection logs were completed, and there was no QAPI documentation for 2020, 2021, and 2022. On 06/13/2023 at 1:30 PM the surveyor conducted an interview with the Administrator / DON. The surveyor asked about Patient 3’s recent hospitalizations. The Administrator stated Patient 3 was hospitalized for COVID-19 in March of 2023, and then was re hospitalized in May of 2023 for COVID-19 and Pneumonia infections. The surveyor stated there were no infection reports for 2020, 2021, 2022, and through June 2023 in the Infection Control and QAPI documents provided. The Administrator stated: “I didn’t do an infection report because the family said Patient 3 was sick and transferred to the ED, and another time Patient 3 was ill, and I sent him to the hospital. I didn’t do one (an infection report). The surveyor asked when the Administrator would complete an infection control report. The Administrator stated: “If I was the one who transferred the Patient to the hospital.” The Administrator / DON stated: The family member told me the infection “was resolved in the hospital, both the Pneumonia and COVID.” The Administrator stated they had not done any infection logs because the COVID-19 infection “was diagnosed in the hospital.” An interview was conducted with the Administrator on 06/13/2023 at 2:30 PM. The surveyor shared the findings of the review of the QAPI documents provided including Infection control activity documentation. The surveyor asked if the policy 9.1 titled Quality Assessment Performance Improvement Plan with a revision date of 01/29/2020 found in the policy and procedures manual provided was the correct plan. The Administrator stated: “Yes.” The surveyor asked about the lack of current QAPI documents. The Administrator stated the previous owner had gone over plan with the Administrator in February 2022, and the Administrator stated they had not done any QAPI activities since that review. The surveyor asked why the Agency had not implemented the plan policies for 2020, 2021, 2022, and 2023 and the Administrator stated: “because I have a lot of things going on, lots of paperwork, the visits, and I was hoping to grow a little to hire staff.” The Administrator stated: “My sister (the Alternate Administrator) is a Family Nurse Practitioner and is going to move here, and we will be in better shape. We don’t have enough to hire help.” Agency policy titled: “10.1 Infection Control Program” dated 01/29/2020 read in part: The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral pert of the HHA’s quality assessment and performance improvement (QAPI) program… Management will be responsible for coordinating all activities related to the Infection Control Program … Documentation will include at a minimum: date infection was detected, client’s name, primary diagnosis, signs/symptoms, sources of infection, type of infection, modes of transmission Pathogen identified, if any Treatment, when treatment began and when it ends, Summaries of reviews, trend composites, recommendations, and related performance improvement activities will be maintained by Agency…An “Infection Control Report” will be completed within 48 working hours and submitted to Patient Care Manager / QAPI Coordinator… The Infection Control Team / QAPI Committee will review all reports and analyze the data, noting trends / patterns. Recommendations needing follow-up will be reported to Governing Body….” Agency policy titled: “9.1 Quality Assessment Performance Improvement Plan” dated 01/29/2020 read in part: “The Agency will develop, implement, and maintain and (sic) effective, ongoing HHA-wide, data-driven Quality Assessment Performance Improvement Plan (QAPI) program. The Agency’s governing body will ensure that the program reflects the complexity of its organization and services; involves all Agency services (including those services provided under contract … Areas for improvement will be identified through the collection of data for analysis of Agency services. Systems of measure include a. Agency derived documentation (including): …Infection Control activities…”

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the Administrator / DON failed to be responsible for all day to day operations of the Home Health Agency and failed to implement, enforce and monitor adherence to the written policies for QAPI, Emergency Preparedness, Patient Care, Complaint Investigations, and Infection control for 3 (June of 2020, 2021, 2022, and through June 2023) of 3 years of the survey review. Patients and staff were subjected to potentially unsafe and substandard care. QAPI and Infection Control The surveyor requested the Infection Control and QAPI documents for the last three years during the opening conference on May 26, 2023. The surveyor reviewed a three-ring binder provided by the Administrator on 06/09/2023 at 2:15 PM. The binder contained no evidence of tracking of any infections, no infection logs were completed, and there was no QAPI documentation for 2020, 2021, and 2022. On 06/13/2023 at 1:30 PM the surveyor conducted an interview with the Administrator / DON. The surveyor asked about Patient 3’s recent hospitalizations. The Administrator stated Patient 3 was hospitalized for COVID-19 in March of 2023, and then was rehospitalized in May of 2023 for COVID-19 and Pneumonia infections. The surveyor stated there were no infection reports for 2020, 2021, 2022, and through June 2023 in the Infection Control and QAPI documents provided. The Administrator stated: “I didn’t do an infection report because the family said he was sick and transferred to the ED, and another time Patient 3 was ill, and I sent him to the hospital. I didn’t do one (an infection report). The surveyor asked when the Administrator would complete an infection control report. The Administrator stated: “If I was the one who transferred the Patient to the hospital.” The Administrator / DON stated: The family member told me the infection “was resolved in the hospital, both the Pneumonia and Covid.” The Administrator stated they had not done any infection logs because the COVID-19 infection “was diagnosed in the hospital.” An interview was conducted with the Administrator / DON on 06/13/2023 at 2:30 PM. The surveyor shared the findings of the review of the QAPI documents provided including Infection control activity documentation. The surveyor asked if the policy 9.1 titled Quality Assessment Performance Improvement Plan with a revision date of 01/29/2020 found in the policy and procedures manual provided was the correct plan. The Administrator stated: “Yes.” The surveyor asked about the lack of current QAPI documents. The Administrator stated the previous owner had gone over the plan with the Administrator in February 2022, and the Administrator stated they had not done any QAPI activities since that review. The surveyor asked why the Agency had not implemented the plan policies for 2020, 2021, 2022, and 2023 and the Administrator stated: “because I have a lot of things going on, lots of paperwork, the visits, and I was hoping to grow a little to hire staff.” The Administrator stated: “My sister (the Alternate Administrator) is a Family Nurse Practitioner and is going to move here, and we will be in better shape. We don’t have enough to hire help.” Agency policy titled: “10.1 Infection Control Program” dated 01/29/2020 read in part: The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program… Management will be responsible for coordinating all activities related to the Infection Control Program … Documentation will include at a minimum: date infection was detected, client’s name, primary diagnosis, signs/symptoms, sources of infection, type of infection, modes of transmission Pathogen identified, if any Treatment, when treatment began and when it ends, Summaries of reviews, trend composites, recommendations, and related performance improvement activities will be maintained by Agency…An “Infection Control Report” will be completed within 48 working hours and submitted to Patient Care Manager / QAPI Coordinator… The Infection Control Team / QAPI Committee will review all reports and analyze the data, noting trends / patterns. Recommendations needing follow-up will be reported to Governing Body….” Agency policy titled: “9.1 Quality Assessment Performance Improvement Plan” dated 01/29/2020 read in part: “The Agency will develop, implement, and maintain and (sic) effective, ongoing HHA-wide, data-driven Quality Assessment Performance Improvement Plan (QAPI) program. The Agency’s governing body will ensure that the program reflects the complexity of its organization and services; involves all Agency services (including those services provided under contract … Areas for improvement will be identified through the collection of data for analysis of Agency services. Systems of measure include a. Agency derived documentation (including): …Infection Control activities…” Agency policy titled: “9.1 Quality Assessment Performance Improvement Plan” dated 01/29/2020 read in part: “The Agency will develop, implement and maintain and (sic) effective, ongoing HHA-wide, data-driven Quality Assessment Performance Improvement Plan (QAPI) program. The Agency’s governing body will ensure that the program reflects the complexity of its organization and services; involves all Agency services (including those services provided under contract … Areas for improvement will be identified through the collection od data for analysis of Agency services. Systems of measure include a. Agency derived documentation (including): …Patient complaints and satisfaction survey data, including agency response to complaints…” Emergency Preparedness The agency failed to complete an internal review of the Emergency Preparedness plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed for 3 (2020, 2021, and 2022) 3 of the years of the survey review period. The surveyor requested the Emergency preparedness plan documents for the last three years during the opening conference on May 26, 2023. The surveyor reviewed a three-ring binder provided by the Administrator on 06/09/2023. The binder contained no evidence of an annual review of the emergency plan for 2020, 2021, and 2022. The binder contained a risk assessment plan dated 01/31/10 and documented the risk from epidemic as “None.” Review of the entire binder failed to find a more current risk assessment. The binder contained emergency preparedness policy and plan dated 080111. An interview was conducted with the Administrator on 06/13/23 at 12:59 PM. The surveyor shared the findings of the review of the emergency preparedness plan, lack of evaluations of the plan, and lack of updates to the risk assessment documents provided. The Administrator clarified the correct Emergency preparedness policy and response plan in the policy manual provided and was dated 01/29/2020. The Administrator stated: “the previous owner went over (the emergency preparedness program) with me in February 2022, and I have not done anything with it since 2022.” The surveyor asked if the Administrator had any additional emergency preparedness documents to provide for review and the Administrator stated: “No.” Agency policy titled 7.8 Emergency Preparedness and Response Plan read in part: “The agency will develop, maintain, and implement a written Emergency preparedness and Response Plan (Plan), based on the Agency’s risk assessment. It establishes a plan of action for providing continuous patient care and continuous business operations in the event of a disaster… The effectiveness of the Emergency Preparedness Plan and Response will be evaluated at least annually to evaluate its effectiveness, and after each actual emergency response. Results will be included in the Agency’s Annual program evaluation and updated as needed…” Patient Care Policies Patient 3 and 5 – the care plan failed to include all necessary interventions to address the underlying risk factors of the dialysis access site. Patient 1, 2 and 4 the care plan failed to include interventions to address the diabetes primary diagnosis, and a statement of risks for hospitalization and emergency room visits. Patient 6 the care plan failed to include a statement of risks for hospitalization, all pertinent diagnoses, and all medications. Review of Patient 3’s record revealed no assessment of the dialysis access location or type of access for comprehensive assessments dated 02/24/2023, 04/17/2023, and 04/26/2023. Review of Patient 3’s plan of care for 02/28/23 to 04/28/23 revealed a diagnosis of end stage renal disease (complete kidney failure) and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the dialysis access site (a surgical procedure to join and vein and artery to allow for higher pressure and faster blood flow to allow for hemodialysis.) Review of Patient 3’s record revealed no assessment of the dialysis access location or type of access for comprehensive assessments dated, 06/02/2022, 07/24/202, and 08/12/2022. Review of the nursing notes dated 03/01/23, 03/06/23, 03/13/23, 03/20/23, 03/27/23, and 04/05/23 revealed no assessment of the client’s dialysis access site. During a home visit on 06/05/2023 at 3:15 PM the surveyor observed the Administrator / DON provide the weekly nursing visit. The surveyor observed the entire visit and noted the nurse did not assess the dialysis access site, and did not ask the client or the family member about the dialysis access site. An interview was conducted on 06/08/23 at 3:32 PM with the Administrator / DON. The surveyor reviewed the plan of care, assessment, and observation visit findings for Patient 3 with the Administrator/DON. The surveyor asked why there were no orders to assess the dialysis access site, The Administrator / Supervising Nurse stated: “There is no place for it in (the electronic medical record). I should have done paper charts, I would have done better.” The surveyor asked why the nurses notes and assessments contained no evidence of assessment of the patient’s dialysis access site, and why the nurse didn’t assess the dialysis access site during the home visit made with the surveyor. The Administrator / DON stated: “I look but I don’t assess it (the dialysis access site), because I am not the provider for dialysis. How would I assess, what is the reason, I haven’t had any complaints, and I haven’t looked.” Review of Patient 5’s plan of care for 06/06/2022 to 08/04/2022 revealed a diagnosis of end stage renal disease (complete kidney failure). The POC had orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the dialysis access site. Review of the nursing notes dated 06/07/22, 06/14/22, 07/05/22, 07/12/22, 07/18/2022, 07/19/22, and 07/26/2022 revealed no assessment of Patient 5’s dialysis access site. Review of Patient 5’s record revealed no assessment of the dialysis access location or type of access for comprehensive assessments dated, 06/02/2022, 07/24/202, and 08/12/2022. An interview was conducted on 06/08/23 at 4:43 PM with the Administrator / DON. The surveyor reviewed the plan of care findings for Patient 5 and asked why there were no orders to assess the dialysis access site, and why the assessments contained no evidence of assessment, and visit notes failed to contain the location or status of Patient 5’s dialysis access site. The Administrator/ DON reviewed the record and stated: “I think it is something I have to type it in [into the electronic medical record note]. The Administrator stated: “I told you, at that time, I was getting my hands on the electronic medical record, and that is why.” The surveyor asked if the Administrator was learning to use the electronic medical record at the time of this documentation. The Administrator stated that was correct. Review of Patient 1’s plan of care for 02/14/23 to 04/14/23 revealed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Cataract (blood sugar metabolism disorder and clouding of the lens of the eye), and Alzheimer’s (dementia) and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the client’s blood sugars during nursing visits. The POC failed to include a statement of risks for hospitalization and emergency room visits. Review of the nursing notes dated 02/15/23, 02/22/23, 03/01/23, 03/08/23, 03/15/23, 03/21/23, 03/28/23, and 04/05/23 revealed no assessment of the client’s blood sugars. During a home visit on 06/05/2023 at 1:15 PM the surveyor observed the Administrator / DON provide the weekly nursing visit with client 1. The surveyor observed the entire visit and noted the nurse did not check the blood sugar of Patient 1 or ask the family member about the patient’s blood sugar results. The surveyor asked the family member if they were checking the patient’s blood sugars near the end of the visit, and the family member showed the surveyor a log that ended in December 2022 and stated they were not checking the client’s blood sugars since the client came home from the hospital in December of 2022. An interview was conducted on 06/08/23 at 3:15 PM with the Administrator / DON. The surveyor reviewed the plan of care and visit note findings for Patient 1 and asked why there were no orders for the nurse to check the blood sugar, no statement of risks for hospitalization and emergency room visits, and why the nurses’ notes from February and March 2023 contained no evidence of assessment of the patient’s blood sugars. The Administrator/ DON reviewed the record and stated she did not see orders to check the blood sugars on the POC. The Administrator / DON stated that “my downfall is the electronic medical record” The Administrator stated they did not know where to enter the risks for hospitalization and emergency room visits in the electronic medical record. The Administrator stated: “Even if I know what to do, I don’t know how to transcribe it.” Review of Patient 2’s plan of care for 02/14/23 to 04/14/23 revealed a primary diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the patient’s blood sugars during nursing visits. The POC failed to include a statement of risks for hospitalization and emergency room visits. Review of the nursing notes dated 04/19/23 and 05/09/23 revealed the nurse documented teaching about insulin during the visits. The Plan of care did not contain insulin in the medication list. During a home visit on 06/05/2023 at 2:15 PM the surveyor observed the Administrator / DON provide the weekly nursing visit for Patient 2. The surveyor observed the entire visit and noted the nurse did not assess the bottom of the patient’s feet, did not check the blood sugar of Patient 2, and did not ask to see the blood sugar results on the glucometer. The surveyor asked Patient 2 if they would retrieve their glucometer so the surveyor could review the history of blood sugars at the end of the visit. Patient 2 brought the glucometer to the nurse and the surveyor. The Administrator / DON then reviewed the history on the glucometer and briefly turned it toward the surveyor and stated it indicated a blood sugar of 156. The surveyor asked if the patient was on insulin. Patient 2 stated they were not on insulin, and the nurse asked Patient 2 if they were still taking garlic for their blood sugar. Patient 2 stated they did take garlic today and their other medications. An interview was conducted on 06/08/23 at 3:00 PM with the Administrator / DON. The surveyor reviewed the plan of care, clinical record review, and observation findings for Patient 2 and asked why there were no orders for the nurse to check the blood sugar and no statement of risks for hospitalization and emergency room visits. The Administrator/DON reviewed the record and stated she did not see orders to check the blood sugars on the POC. The Administrator / DON stated she should have assessed the bottom of the client’s feet. The DON stated that was the main thing they were working on for Patient 2 and the orders should be on the POC. The surveyor asked about the lack of statement of risks for hospitalization and emergency room visits. The Administrator / DON stated: “I don’t know where it is supposed to be.” The surveyor asked if the Administrator /DON meant where to put it in the electronic medical record. The Administrator / DON stated “Yes.” The surveyor asked if Patient 2 was on insulin, and about the nurses’ notes dated 04/19/23 and 05/09/23 that documented that the Administrator / DON taught insulin. The Administrator / DON stated Patient 2 “never had it (Insulin), and I have never taught it. Why is it on the note? I think it is a typo. I am surprised, maybe I was sleeping.” The Administrator / DON stated: “Every time (I visit) Patient 2 has a big box and I show her how to do it (check the blood sugar), and Patient 2 does it for me. Because Patient 2 told me what the sugar was (on the visit made with the surveyor on 06/05/20230, I didn’t ask to see her machine.” The Administrator / DON stated she should have checked the bottom of her feet and she usually does. Review of Patient 4’s plan of care for 02/07/23 to 04/07/23 revealed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy (blood sugar metabolism disorder and nerve damage to the feet) and orders for weekly nursing visits. Review of the entire plan of care revealed no orders for the assessment of the client’s blood sugars during nursing visits, no other orders for care of the client with Diabetes and Neuropathy. The POC also failed to include a statement of risks for hospitalization and emergency room visits. Review of the nursing notes dated 02/10/23, 02/15/23, 02/22/23, 03/08/23, 03/14/23, and 03/28/23, revealed the same narrative on each of the notes as follows: “SN met patient at home and checked all vital signs. Patient states she has a death in the family, and she is worried. SN discussed stress management with patient and did medication reconciliation. SN checked blood sugar and it was 156. Patient just ate noodles and blood sugar is a little elevated. Patient states, she was having some headaches yesterday, but she stated she feels well today.” An interview was conducted on 06/08/23 at 4:32 PM with the Administrator / DON. The surveyor reviewed the plan of care and visit note findings for Patient 4 and asked why there were no orders for the nurse to check the blood sugar, no orders for care of the client with Diabetes and Neuropathy, and no statement of risks for hospitalization and emergency room visits. The Administrator/ DON reviewed the record and stated she did not see orders to check the blood sugars on the POC. The Administrator / DON stated: “There are no orders for finger stick Q (every) visit. It is not available in (the electronic medical record) as a choice. “Someone told me we don’t do the finger sticks for every patient. We don’t use our own machine, and we don’t know if people (patients) will do them. We teach the caregivers, that is probably why it isn’t on the plan of care.” The surveyor asked why the narrative notes are the same on the visit notes. The Administrator / DON stated: “You can pull (the notes) forward if nothing has happened, and you have to change your narrative. So, I just pulled them forward and forgot to change my narrative.” Review of Patient 6’s plan of care for 02/22/23 to 04/22/23 revealed a primary diagnosis of Essential Hypertension (high blood pressure), Atrial Fibrillation (rapid and irregular heart rate), and Anemia (low iron in the blood cells), Review of the entire Plan of Care failed to find a diagnosis of Constipation. Review of the entire plan of care revealed no statement of risks for hospitalization, orders for care of constipation, and medications to treat Constipation. Nurse’s notes for Patient 6 dated 02/23/2023, 03/08/2023, 03/21/23 in the visit narrative section read: “Patient states, she is having constipations because she stated she has not had a BM in 3 days. SN advised patient to take fiber and drink water to give her free bowel…. SN advised patient about over the counter stool softeners if natural remedies does not work. Patient also c/o pain in the left upper abdominal quadrant. Patient states, she layed (sic) down for a while and the pain went away.” An interview was conducted on 06/08/23 at 1:21 PM with the Administrator / DON. The surveyor reviewed the plan of care and visit note findings for Patient 6. The surveyor asked about the recommendations for treatment in the notes. The Administrator / DON stated it is regular (nutrition requirements) on the POC. “I was talking about fiber from previous notes and it just copied forward on the other notes.” The surveyor asked why the diagnosis, medications, and treatment recommendations were not on the POC. The Administrator / DON stated: “The doctor never gave orders, she has liver issues, polys in liver and the doctor knows (about the constipation).” The Administrator / DON stated: “After three days it resolved. Maybe she has over the counter stool softeners?.” The surveyor asked why those were not included in the medications listed on the POC. The Administrator / DON reviewed medications listed on the POC and stated: “she doesn’t have it in there, no medications on the POC and no diet issues, no dx no medications, nothing on the POC, just home remedies, the doctor is very careful, for it not being on the POC, it is not on the POC.“ The surveyor asked why the POC failed to contain the required statement of risks for hospitalization and ER visits. The Administrator / DON reviewed the POC and stated: “I am trying to find out where to put it. Do you know what heading in the (electronic medical record) it is, so I can find it?” The Administrator / DON stated: “The reason is I don’t find it is I don’t see where to put it in the recert (recertification).” Agency policy titled: 4.4 Patient Reassessment dated 01/29/2020 read in part: Each patient must receive the home health services that are written in an individualized plan of care …The individualized plan of care must include the following: All pertinent diagnoses, … all medications and treatments… A description of the patient’s risk for emergency department visits and hospital re-admission, all necessary interventions to address the underlying risk factors. Patient-specific interventions and education; … All patient care orders, including verbal orders, must be recorded in the plan of care… Agency policy titled: 5.7 Care Planning Process dated 01/29/2020 read in part: The Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and / or needs…. Each patient/client must receive an individualized POC, including any revisions or additions. The individualized POC must specify the care and services necessary to meet the patient/client needs as identified in the comprehensive assessment… Review of agency policy and procedures titled: 4.2 Patient Assessment Guidelines with a revision date of 01/29/2020 read in part: The Agency will utilize and adhere to a defined comprehensive assessment in order to identify the patient’s needs for home care and that meets the patient’s medical, nursing, rehabilitative, social and discharge planning needs. Review of agency policy and procedures titled: 8.8 Client Records Content with a revision date of 01/29/2020 read in part: The Agency must maintain a clinical record containing past and current information for every client 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… Complaint Investigations The surveyor requested the complaint log documentation for the previous three years during the opening conference on 5/26/20233 at 1:40 PM. The surveyor reviewed the three- ring binder titled “Complaint Log” provided by the Administrator on 06/09/2023. The surveyor noted one complaint dated 03/15/22 regarding nursing services for Patient 4. The complaint was regarding the nurse arriving late for a visit. The was complaint documented by the Alternate DON and dates were blank after sections titled: “Action Taken” and “Resolution/Follow-Up.” There were no other complaints documented in the Complaint Log. The surveyor reviewed the QAPI information provided by the agency on 06/09/2023 and found no information about complaints in the QAPI information provided for 2020, 2021, 2022, and 2023. Review of Patient 1’s clinical record revealed PT A provided services in October 2022. Patient 1’s clinical record revealed PT services currently being provided by PT B. There was no documentation of a complaint in Patient 1’s clinical record. An interview was conducted with the family member for Patient 1 on 06/09/23 at 3:02 PM. The surveyor asked the family member about the nursing and PT services Patient 1 received from the agency. The family member stated the patient and family did not like the first PT that had provided PT services and they do like the one they have now. The surveyor asked if they reported this to the agency and the family member stated they did report this to the Administrator / DON and they had assigned a different PT. On 06/13/23 at 12:59 PM the surveyor conducted an interview with the Administrator and an HHS staff member who acted as a translator. The surveyor asked about the PT services for Patient #1. The Administrator stated: At the start of care, I used Contract Therapy provider AA and “he was harsh on Patient 1, and the family asked to change therapists.” The surveyor asked what the Administrator did in response to the family member’s report about the therapist. The Administrator stated they talked to PT A who said he “did what we are we there for”. The Administrator stated they told PT A they understood PT A wanting to push Patient 1, and that the Administrator also felt PT A was not supporting the patient’s rights to refuse care. The Administrator stated when PT was ordered again for Patient 1 “I changed to a different PT contractor.” The surveyor shared the results of the review of the Agency QAPI program and complaint log information provided and asked about the lack of dates for actions taken and resolution for the March 15, 2022 complaint. The Administrator stated the bottom of the form was signed. The surveyor shared the findings of no complaint found about the PT services for Patient 1 in the complaint log. The Administrator reviewed the complaint log and stated they didn’t find it. The Administrator stated: “I have a folder in my car which is filing, and it may be there.” The surveyor asked if the complaint was received in October 2022 when PT A was assigned to provide services for Patient 1. The Administrator stated: “Yes.” The surveyor offered the opportunity for the agency to provide additional documentation prior to the exit conference and no additional information or documentation was provided. Agency policy titled: “3.1 Patient Bill of Rights and Responsibilities” dated 01/29/2020 read in part: “The Agency must protect and promote the exercise of these rights…Agency staff will be responsible for knowing, observing, and implementing the patient’s rights… The Patient Bill of Rights must include, but not be limited to: … To voice grievances regarding treatment or care that is or fails to be furnished… Any HHA staff whether employed directly or under arrangements in the normal course of providing services to patients, who identifies, notices or recognizes incidences or these circumstances must report this to the HHA and the Agency must investigate complaints made by the patient/ the patient’s representative/ and the patient’s caregiver / and family regarding treatment or care that is (or fails to be furnished … by anyone furnishing services on behalf of the Agency and must document the existence of the complaint and the resolution of the complaint. Take action to prevent further potential violations while the complaint is being investigated…” Agency policy titled: “1.6 Responsibilities of the Administrator” dated 01/29/2023 read in part: The Agency Administrator will be responsible for all day to day operations of a Home Health Agency and for implementing and supervising the administrative policies and operations of the Agency and for supervising the provision of all services to agency clients on a day to day basis. Will be responsible for ensuring that a skilled professional … is available during all operating hours… The Agency Administrator will be responsible for reporting and ongoing communication with the Governing body, Professional Advisory Committee and Agency staff…