Every finding on record at Optimal Home Health

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 36459, Health Facilities Evaluator Nurse Surveyor # 43979, Health Facilities Evaluator Nurse Unduplicated Admissions - 219 Active Patients - 54 Sample Size - 10 Patients Home Visits – 3

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to review and update their policy and procedure for emergency preparedness. This deficient practice has the potential to affect the safety of the patients and put them at risk for delayed services in the event of an emergency or disaster. On 05/09/2022, a review of the agency’s emergency preparedness program was conducted. The policy and procedure provided by the Director of Patient Care Services (DPCS), indicated that the policy and procedure was revised on 01/2020 During an interview with the DPCS on 05/09/2022, at 2:33 p.m., he stated that the emergency preparedness policy and procedure is updated annually. A review of the agency’s policy and procedure titled “Emergency Operations Plan & Policies,” dated 01/2020, indicated that the emergency preparedness program includes the agency developing and maintaining an emergency preparedness plan and policies that are reviewed and updated at least every two years.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to develop and maintain a training program for the agency staff to ensure each employee is able to perform their duties in the event of an emergency or disaster. This deficient practice has the potential to affect the safety of the patients and put them at risk for delayed services if staff are not efficient in providing care to patients in a timely manner in the event of an emergency or disaster. On 05/09/2022, a review of the agency’s emergency preparedness program was conducted. The emergency preparedness training log for the staff was requested from the Director of Patient Care Services (DPCS). During an interview with the DPCS 05/09/2022, at 2:33 p.m., he stated that there was no log or documentation that emergency preparedness training, in-service and drills for staff was conducted. The DPCS further stated the staff training, in-services and drills should have been conducted annually. A review of the agency’s policy and procedure titled “Emergency Operations Plan & Policies,” dated 01/2020, indicated that the agency complies with all applicable federal, state and local emergency preparedness requirements. The policy and procedure further indicated that the agency has established and maintained an emergency preparedness program that meets all requirements.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to develop and maintain a testing program for all staffs to ensure each staff is aware of their duties in the event of an emergency or disaster. This deficient practice has the potential to affect the safety of the patients and put them at risk for delayed services if staff are not efficient in providing care to patients in a timely manner in the event of an emergency or disaster. On 05/09/2022, a review of the agency’s emergency preparedness program was conducted. The emergency preparedness testing log for the staff was requested from the Director of Patient Care Services (DPCS). During an interview with the DPCS 05/09/2022, at 2:33 p.m., he stated that there was no log or documentation that emergency preparedness training, in-service and drills for staff was conducted. The DPCS further stated that staff training, in-services and drills, should have been conducted annually. A review of the agency’s policy and procedure titled “Emergency Operations Plan & Policies,” dated 01/2020, indicated that the agency complies with all applicable federal, state and local emergency preparedness requirements. The policy and procedure further indicated that the agency has established and maintained an emergency preparedness program that meets all requirements.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 36459, Health Facilities Evaluator Nurse Surveyor # 43979, Health Facilities Evaluator Nurse Unduplicated Admissions - 219 Active Patients - 54 Sample Size - 10 Patients Home Visits – 3 On 5/10/2022 at 5:16 p.m., an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the agency’s Administrator (ADM) and the Chief Executive Officer (CEO) for the facility’s failure to ensure COVID-19 policies and procedures were developed and implemented. On 5/11/2022 at 4:39 p.m., the IJ was removed after the agency submitted an IJ Removal Plan in the presence of the ADM and the agency office staff. The survey team verified and confirmed during onsite, the implementation of the removal plan, through interviews and record reviews. The following Conditions of Participation were not met: CFR 484.45 Reporting OASIS Information CFR 484.60 Care Planning, Coordination, and Quality of Care CFR 484.70 Infection Control CFR 484.75 Skilled Professional Services CFR 484.105 Organization and Administration of Services CFR 484.110 Clinical Records

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that the Condition of Participation for Reporting OASIS Information was met as follows: The HHA failed to ensure, the Outcome and Assessment Information Set (OASIS, used to collect and report assessment data) were accurately reflect the patient's health status at the time of the assessment, for two of 10 sampled patients (Patients 3 and 6). Patient 3's OASIS dated 4/20/22, indicated, the patient had stage 3 pressure ulcer (areas of localized damage to the skin and underlying tissue) on the left heel, but no pressure ulcer was observed on 5/5/2022. Patient 6 was listed as active patient, the agency did not submit a discharge OASIS, when the patient passed away on4/6/2022 . (Refer to G 374). The cumulative effect of these systemic practices resulted in the home health agency's failure to ensure the patient's OASIS reflect the patient's current health status for provision of quality health care in a safe environment. Findings: The HHA failed to: Ensure the agency staff transmitted the accurate patient status in the OASIS sent to the CMS (refer to G374).

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to ensure the Outcome and Assessment Information Set (OASIS) transmitted to the Centers for Medicare & Medicaid Services (CMS) were accurate and reflected the status of the patients at the time of the assessment, for two of 10 patients (Patients 3 and 6). This failure had the potential to result in an inconsistent assessment of the patient's status transmitted to CMS that could lead to inaccurate care and payment or disbursements of services provided to the patients. During a review of Patient 6’s “Patient Demographic” indicated Patient 6 was admitted on 11/2/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). During a review of Patient 6’s “Plan of Care” dated 3/2/2022 – 4/30/2022 indicated Patient 6 was oriented and forgetful. Patient 6 had Skilled Nursing visits ordered once a week for nine weeks. SN to perform at every visit: vital signs, blood sugar, weight, and document, and Oxygen (02) saturation reading. Normal O2 saturation level is between 95% - 100%. During an interview on 5/5/2022, at 2:15 p.m., with Administrator (ADM), the ADM stated that the Reporting of Outcome and Assessment Information Set (OASIS) is signed the next day after discussing the case. During an interview on 5/5/2022, at 2:28 p.m., with ADM, the ADM stated that the Reporting of Outcome and Assessment Information Set (OASIS) needs to be turned in within 5 days. ADM stated that once he goes over the OASIS with the nurse he signs it, making sure everything is completed. During a concurrent interview and record review on 5/6/2022, at 1:15 p.m., with ADM of Patient 6’s electronic medical record, the medical record was reviewed. ADM stated that he was not aware that Patient 6 had been discharged. ADM stated they have 3 days to document a discharge OASIS. ADM stated that Patient 6 was discharge by Physical Therapy (PT), therefore, he had to go into PT’s portal to retrieve the discharge OASIS and transmitted to CMS, which he has not done. ADM stated that it is up to the HHA to look in PT's portal for the discharge OASIS. During a concurrent interview and record review on 5/6/2022, at 1:20 p.m., with ADM of facility’s “Patient Census Report” dated 5/4/2022, the patient census was reviewed. ADM stated that the Patient Census Report listed Patient 6 as a current patient. ‘ During a concurrent interview and record review on 5/6/2022, at 3 p.m., with ADM stated, “Apparently, the patient expired on 4/6, was reported to HHA on 4/8”. ADM stated that was his responsibility to check PT’s portal. During a concurrent interview and record review on 5/9/2022 at 12:30 p.m. with ADM of facility’s “Patient Census Report” dated 5/9/2022, the Patient census was reviewed. ADM stated that the Patient Census Report listed Patient 6 as a current patient. ADM stated that Patient 6’s name is listed as a current patient due to her discharge OASIS not being submitted. ADM stated that the current census gets generated by having a discharge OASIS. A review of facility’s policy titled, “Discharge Criteria and Process” dated October 2015 indicated “Services will be terminated when the patient meets one (1) or more of the following discharge criteria: The patient or family/caregiver refuses or discontinues care. The patient expires… An update to the comprehensive assessment, including required OASIS data elements, will be completed, as required by regulation… All discharge paperwork will be due in the office within 72 hours of the discharge date. This will include the discharge order, discharge summary, plan of care, medication profile, and OASIS. Findings: a. A review of Patient 3's clinical record indicated a start of care date (SOC) of 04/18/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, Stage 3 (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure ulcer to left and right buttocks. A review of Patient 3's Plan of Care (POC) for the certification period of 04/18/2022 to 06/16/2022, indicated for the skilled nurse (SN) to visit the patient two times a week for two weeks and one time a week for seven weeks. The POC indicated for the the SN to perform a complete physical assessment each visit with emphasis on disease process. The POC further indicated the SN was to assess the disease process of stage 3 pressure ulcer to the right heel, left heel, and right buttock. A review of Patient 3’s OASIS with an assessment date of 04/20/2022, indicated that patient had a diagnosis that included a stage 3 pressure ulcer of right heel, stage 3 pressure ulcer of left heel, stage 3 pressure ulcer of right buttock, and stage 3 pressure ulcer of left buttock. Further review of Patient 3’s OASIS indicated, the patient had four stage 3 unhealed pressure ulcers. On 05/05/2022, at 10:55 p.m., a joint home visit with the Director of Patient Care Services (DPCS) was conducted at Patient 3’s residence. Patient 3 was observed sitting on a chair and DPCS proceeded to do a skin assessment on the patient. During an observation of DPCS skin assessment, it was observed that Patient 3 did not have a Stage III pressure ulcer to his left heel, left buttock and right buttock. Patient 3's left heel was covered with gauze, however there was no pressure ulcer. During an interview with Patient 3’s Family Member on 05/05/2022, at 11:20 a.m., she stated that the patient only had a wound to his left heel and no other wounds. During an interview with the Registered Nurse (RN 4) 05/06/2022 at 1:32 p.m., she stated that she was the nurse who did the initial comprehensive assessment for Patient 3. RN 4 stated that during her initial assessment with Patient 3, he did not have stage three pressure ulcers to his right buttock, left buttocks, right heel and left heel. RN 4 further stated that Patient 4’s OASIS must have been edited after she submitted it because she did not put stage three pressure ulcers on her assessment. During an interview with the DPCS 05/06/2022 at 1:50 p.m., he stated that he was the only one who had access to editing the OASIS. DPCS stated, he edited Patient 3’s OASIS, and that RN 4 was the one who did the initial assessment on 04/20/2022. DPCS further stated he should have not been editing nursing notes that another staff member did. A review of the agency’s policy and procedure titled “Initial and Comprehensive Assessment,” undated, indicated that the comprehensive assessment for each patient must be completed in its entirety by the same clinician. A review of the agency’s policy and procedure titled “Reporting of OASIS Information,” dated 02/2021, indicated that the agency will report electronically all OASIS data collected according to current federal and/or state requirements. The policy and procedure further indicated that the agency staff will ensure that the accuracy of OASIS data reflects the patient’s status at time of assessment and data collections.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to review and document all the medications the patient is currently using for 2 of 10 sampled patients (Patients 3 and 6). This failure had the potential to result in placing the patients at risk for drug interactions, adverse actions, and medication errors that could affect the patient's already compromised health status. During a review of Patient 7’s “Patient Demographic” indicated Patient 7 was admitted on 4/2/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). During a review of Patient 7’s “Home Health Certificate and Plan of Care (POC)” dated 4/2/2022 to 5/31/2022 indicated Patient 7 had Skilled Nursing (SN) 1 visits per week for 1 week then, 2 visits per week for 2 weeks then, 1 visit per week for 6 weeks. The POC also indicated the SN is to perform management of current/new/changed (appropriate medication for the first diagnosis) medications, actions/side effects/adverse reactions and importance of compliance at every visit. During a concurrent interview and record review on 5/5/2022 at 10:55 a.m. with LVN9 while on a joint home visit of Patient 7’s HHA medication profile, LVN 9 stated that she checks Patient 7’s medication once a week but, she does not recall if she checked last week. LVN 9 stated that it was important to check medication and if there was an issue or a change the medical doctor should be notified. LVN 9 stated that she calls the HHA to let them know when there are changes, but she does not know what happens after that. Patient 7’s medication profile indicated Patient 7 was currently taking: -Mega Vitamin K2 1 tablet oral daily, -Trelegy Elipta 100 micrograms (mcg)/62.5mcg 1 puff by mouth daily, -Melatonin 1 milligrams (mg) 1 tablet oral at bedtime as needed for sleep, -Oxygen 2 liters per minute via nasal cannula continuously, -Alendronate Na 70mg 1 tablet oral every week, -Calcium 600mg 2 tablets oral daily, -Acetylcysteine 205 vial 3 milliliters (ml) 1 inhalation via hand held nebulizer by mouth twice daily, -Losartan Potassium 50mg 1 tablet oral twice per day hold if systolic blood pressure is below 110, - Pantoprazole 40mg 1 tablet oral daily before breakfast, -Escitalopram 10mg 1 tablet oral daily. During a concurrent observation and interview on 5/5/2022, at 11 a.m., with Patient 7 on a joint visit with License Vocational Nurse 9 (LVN 9), Patient 7 stated that the HHA medication profile list was not current. Patient 7 stated that she has not taken Melatonin since arriving from the hospital. Patient 7 stated that she had not taken Losartan since being discharged from the hospital, she stated that the steroids she was receiving in the hospital were making her blood pressure rise, but that she was no longer taking steroids therefore she does not need the Losartan. Patient 7 stated that the doctor told her to take and finish the Arnvity Ellipta she had before going into the hospital before she started taking the Trelegy Elipta. Patient 7 was asked what medications she was taking. Patient 7 provided: -Diliresp 250mg 1 tablet daily x4 weeks. Filled 4/28/2022, Patient 7 stated that she was recently prescribed this medication and she has been taking it since. -Oxygen 2 liters per minute via nasal cannula continuously, -Alendronate Na 70mg 1 tablet oral every week, - Pantoprazole 40mg 1 tablet oral daily before breakfast -Escitalopram 10mg 1 tablet oral daily. -Arvity Ellipta 200mcg Inhalation filled 5/16/2022, patient stated that she has been taking this medication since getting home from the hospital in the beginning of April. -Ipratropium 0.5mg Albuterol 2.5mg/3ml one vial nebulizer three times per day filled 2/3/2022 -Anoro 6.25mcg/25mcg filled 9/23/2021. During a review of Patient 8’s “Patient Demographic” indicated Patient 8 was admitted on 10/1/2021, with a diagnosis of Guillain-Barre Syndrome (a rare disorder in which your body's immune system attacks your nerves) and Pressure Ulcer of left buttocks, stage II (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Patient 8’s “Home Health Certification and Plan of Care” dated 3/30/2022 – 5/28/2022 indicated Patient 8 was alert, oriented, able to focus and shift attention, comprehensive and recalls task directions independently. POC indicated Patient 8 had Skilled Nursing (SN) visits 2 visits per week for 2 weeks, then 1 visit per week for 7 weeks. The POC also indicated the SN was to perform management of current/new/changed (appropriate medication for the first diagnosis) medications, actions/side effects/adverse reactions and importance of compliance at every visit. During an observation on 5/5/2022, at 11 a.m., of Patient 8’s wound treatment provided by LVN1. LVN1 cleanse the left buttocks stage I wound with normal saline, pat dry and applied Nystatin ointment. During a concurrent interview and record review on 5/5/2022, at 11:30 a.m., of Patient 8’s undated “Patient Medication Profile” with LVN1, Patient 8’s medication profile indicated Patient 8 was currently taking: -Left buttocks with pressure sore stage I: cleanse with NS, pat dry, Calmoseptine ointment and then leave open to air daily. Patient care giver (PCG) was willing and capable of doing wound care on non-skilled nursing (SN) days. -Metoprolol 25mg ½ tablet by mouth daily, -Metformin 500mg 1 tablet by mouth twice daily, -Atorvastatin 20mg 1 tablet by mouth daily, -multivitamin 1 tablet by mouth daily. LVN1 stated that she checks the medication profile on every visit and makes changes as needed on the medication profile she filled out. LVN1 stated that she checks the medication profile she made at every visit and that she asks the patient and the care giver if there have been any changes. LVN1 stated that she was following the medication profile I made for her. During a concurrent interview and observation on 5/5/2022 at 11:45 a.m. with Patient 8, Patient 8 was asked which medication she was currently taking, clear plastic box provided by CG, which contained: - Centrum women’s 50+ 1 tablet daily -Mira LAX 1 cap full as needed -Vitamin C 250mg 1 tab daily-D3 125 mcg 1 tab daily -Preservision 1 tabled twice a day -Quinol 100mg 1 tablet every day -Metoprolol 25mg ½ tablet daily -Atorvastatin 20mg 1 tablet daily -Nystatin ointment 100,000 usp Patient 8 stated that she has not been taking Metformin because she believed she did not need it. During an interview on 5/5/2022, at 2:28 p.m., with Administrator (ADM), ADM stated patients medication profile should be checked every visit. ADM was asked the about the importance to reconcile patients medication. ADM stated, "The first concern is patient endangerment. Patients should get well, avoid further, prevent mismanagement of meds". A review of facility’s policy titled, “Medication Profile” revised March 2018 indicated “The nurse or therapist will add all new/changed medications(s) to the medication profile…The medication profile will be reviewed every home visit and updated as changes occur. When Skilled Nursing is ordered, the Registered Nurse (RN) and License Practical Nurse (LPN) review the medications with the patient on an ongoing basis to ensure the understanding of medication use… The medication profile will be accurate.” A review of facility’s policy titled, “Medication Reconciliation” revised February 2021 indicated, “The Agency will reconcile patient’s medications…on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy.” a. A review of Patient 3's clinical record indicated a start of care date (SOC) of 04/18/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, stage three (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and pressure ulcer to left and right buttocks, stage three. A review of Patient 3's Plan of Care (POC) for the certification period of 04/18/2022 to 06/16/2022, indicated that a skilled nurse (SN) is scheduled to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated that the SN is to perform a complete physical assessment each visit with emphasis on disease process. The POC further indicated that the SN is to assess the disease process of stage three pressure ulcer to the right heel, left heel, and right buttock. On 05/05/2022, at 10:55 p.m., a joint home visit with the Director of Patient Care Services (DPCS) was conducted at Patient 3’s residence. A review of Patient 3’s Medication Profile provided by the agency, indicated that patient had an order for Simvastatin (used to treat high cholesterol and triglyceride (fat) levels in the blood) 20 milligrams (mg – unit of measurement) half tablet oral daily, Losartan (used to treat high blood pressure) 50 mg half tablet oral daily, Spironolactone (used to treat high blood pressure and heart failure) 25 mg half tablet oral daily and Alendronate (used to treat and prevent osteoporosis) 70 mg one tablet oral daily. A review of Patient 3’s Simvastatin prescription label on the bottle indicated to take 20 mg, one tablet oral daily at bedtime and a review of patient’s Alendronate prescription label on the box indicated to take 70 mg, one tablet by mouth every seven days. During an interview with Patient 3’s Family Member on 05/05/2022 at 11:05 a.m., she stated that the patient no longer takes Losartan and Spironolactone. Patient 3’s Family Member further stated that the patient takes Alendronate every Sunday. During an interview with the DPCS on 05/09/2022 at 12:22 p.m., he stated that the nurse should do a medication reconciliation and check patient’s medications every visit. A review of the agency’s policy and procedure titled “Medication Reconciliation,” dated 02/2021, indicated that the agency will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy A review of the agency’s policy and procedure titled “Medication Profile,” dated 02/2018, indicated that the medication profile will be reviewed every home visit and updated as changes occur.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health agency (HHA) agency failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: 1. The HHA failed to follow the plan of care (POC) for five of ten patients (Patient 1, 2, 3, 4 and 10). For Patient 1, the Skilled Nurse (SN) did not weigh the patient, did not report blood sugar level to the physician, when the result was 375 milligrams per deciliter (mg/dl, unit of measurement), above the parameters, and did not conduct skin assessment for the patient's pressure ulcer. For Patient 2, the SN did not check the patient ’s blood sugar on one home visit and blood sugar was not reported to the physician, when the result was 365 mg/dl and 389 mg/dl above parameters on two separate home visit, and the patient's oxygen (O2) saturation was not checked. For Patient 3, the agency did not developed not an individualized written plan of care and the patient had missed home visit from the agency. For Patient 4 and 10, the agency did not follow the POC of two home visit every week and had missed home visits. ( Refer to G 572) 2. The HHA failed to obtain a physician order for the administration of Neosporin (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) to the left heel pressure ulcer ((areas of localized damage to the skin and underlying tissue) for one of 10 sampled patients (Patients 3). (Refer to G 580) The cumulative effect of these systemic practices resulted in the home health agency's failure to ensure the plan of care was followed to reach patient goals.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to follow the plan of care (POC) for five of ten sampled patients (Patient 1, 2, 3, 4, and 10). These deficient practices resulted for these patients not receiving the quality of care and services identified in the POC as follows: For Patient 1, the Skilled Nurse (SN) did not weigh the patient, did not report blood sugar level to the physician, when the result was 375 milligram per deciliter (unit of measurement) and was above the parameters, and did not conduct skin assessment, and required patient transferred to the General Acute Care Hospital (GACH) and admitted to the Intensive Care Unit (ICU) for management of diabetic ketoacidosis (DKA, a serious diabetes (serious condition where blood glucose (blood sugar) level too high), complication where the body produces excess blood acids [ketones]), and sepsis secondary to pyelonephritis (urinary tract infection where one or both kidneys become infected)/pressure wounds. For Patient 2, the SN did not check the patient ’s blood sugar on one visit and blood sugar result was reported to the physician, when the result were 365 mg/dl and 389 mg/dl above parameters on two home visit, and the patient's oxygen (O2) saturation was not checked. For Patient 3, the agency did not developed not an individualized written plan of care and the patient had missed home visit from the agency. For Patient 4 and 10, the agency did not follow the POC of two home visit every week and had missed home visits. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 02/10/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 02/10/2022 to 04/10/2022, indicated a skilled nurse (SN) to visit patient two times a week for one weeks, then three times a week for two weeks, then two times a week for two weeks and then one time a week for four weeks. The POC indicated the SN is to perform blood sugar check and weigh Patient 1 every visit and document. The POC the SN is to perform a complete physical assessment each visit with emphasis on disease process. POC indicated the SN is to report to the physician any significant changes in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of Patient 1’s Communication Note dated 02/10/2022 at 4:02 p.m., indicated the SN called the agency to report that patient refused to turn for skin assessment on the back and buttocks areas. The communication note did not indicate that Patient 1 also refused skin assessments on her legs. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/14/2022, indicated that SN assessed patient’s skin integrity from head to toe and patient refused thorough body assessment of back. The Skilled Nurse Visit/Progress Note indicated that patient had right and left heel diabetic ulcers. The Skilled Nurse Visit/Progress Note further indicated that Patient 1’s blood sugar was checked, and the reading was 380. The Skilled Nurse Visit/Progress Note had no documentation of Patient 1’s weight. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/16/2022, indicated that SN checked patient’s blood sugar and the reading was 375. The Skilled Nurse Visit/Progress Note further indicated that SN assessed patient. The Skilled Nurse Visit/Progress Note had no documentation of Patient 1’s weight. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/19/2022, indicated that SN did skin assessment, but patient refused to turn to check the back area and sacral area. The Skilled Nurse Visit/Progress Note further stated that the patient tolerated the wound care well and no signs and symptoms of infection noted. The Skilled Nurse Visit/Progress Note had no documentation of Patient 1’s weight. A review of Patient 1’s Communication Note dated 02/19/2022 at 1:05 p.m., indicated that SN called the agency to report that the patient noted with right lower extremities with purplish in color. A review of Patient 1’s Communication Note dated 02/21/2022 at 12:00 a.m., indicated that SN called the agency to report that patient was admitted to the General Acute Care Hospital (GACH) due to generalized weakness. During an interview with the Registered Nurse (RN 6) at 05/09/2022 at 1:42 p.m., she stated that Patient 1 refused to get her back assessed but that she was able to assess her legs and she did not see anything. During an interview with the DPCS 05/09/2022 at 3:05 p.m., he stated that a head-to-toe assessment was to be conducted every visit and if patient refuses then it should be documented, and physician was to be notified. The DPCS stated that the physician was notified on 02/10/2022 regarding Patient 1’s refusal to get her back assessed but physician was not notified on 02/14/2022 and 02/16/2022. The DPCS further stated that if a patient’s blood sugar is outside parameters the nurse was supposed to notify the agency and the physician. The DPCS stated that LVN 12 did not notify the physician or the agency regarding Patient 1’s blood sugar being outside the parameters on 02/14/2022 and 02/16/2022. DPCS stated that there was no documentation that patient’s weight was checked during the nurse visit. During an interview with the Licensed Vocational Nurse (LVN 4) at 05/10/2022 at 1:26 p.m., he stated that he was also the case manager and that he resigned from the agency on 04/25/2022. LVN 4 stated that when a patient has a change of condition or refuses care then the nurse should document and notify the physician. LVN 4 stated that she did not remember LVN 12 notified him regarding Patient 1’s blood sugar on 02/14/2022 and 02/16/2022. LVN 4 further stated that if LVN 12 did notify him regarding Patient 1’s blood sugar being high then he would have documented it. During an interview with the Licensed Vocational Nurse (LVN 12) at 05/10/2022 at 11:36 a.m., she stated that Patient 1 refused to get her back assessed but she was able to assess her legs and that there was nothing on the legs. LVN 12 stated that she did not report to the physician regarding Patient 1’s blood sugar on 2/14/2022 and 02/16/2022 but she did report to LVN 4. LVN 12 further stated that she did not document that she reported Patient 1’s blood sugar to LVN 4. A review of Patient 1’s Physician Order dated 03/02/2022 at 8: 41 a.m., indicated that patient passed away while at the hospital and to discharge patient from home health services. A review of Patient 1’s GACH records indicated that patient was admitted on 02/21/2022 and admitted to the Intensive Care Unit (ICU) for management of diabetic ketoacidosis (DKA - serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones) and sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) secondary to pyelonephritis (urinary tract infection where one or both kidneys become infected)/pressure wounds. The GACH records further indicated that Patient 1 had Stage III pressure ulcer (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) to the right hip, right posterior (back) superior (upper) lower leg, right lateral (away from the midline of the body) inferior(lower) lower leg, right lateral lower leg, left buttocks, and left superior buttocks. The GACH records indicated that Patient 1 had an unstageable pressure ulcer to the sacrum, right heel, and left heel. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/19/2022, with diagnoses which included type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 2's Plan of Care (POC) for the certification period of 03/20/2022 to 05/18/2022, indicated a skilled nurse (SN) to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated the SN to perform blood sugar and oxygen saturation every visit. POC further indicated for the SN to report to the physician any significant changes in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of Patient 2’s Skilled Nurse Visit/Progress Notes for the certification period of 03/20/2022 to 05/18/2022, indicated that there was no documentation patient's O2 saturation was checked. Patient 2’s Skilled Nurse Visit/Progress Notes further indicated on 03/22/2022 the blood sugar was not checked. Patient 2’s Skilled Nurse Visit/Progress Notes indicated that the random blood sugar on 03/24/2022 was 365 and on 04/07/22 it was 389, there was no documentation that the physician was notified regarding the blood sugar being outside the parameters as indicated in the POC. During an interview with the DPCS 05/09/2022, at 12:50 p.m., he stated that there was no documentation that Patient 2’s O2 saturation was checked during nursing visits. The DPCS further stated Patient 2’s blood sugar should be checked every visit and if blood sugar was outside the parameters the nurse should notify the agency and the physician. c. A review of Patient 3's clinical record indicated a start of care date (SOC) of 04/18/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, stage three (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and pressure ulcer to left and right buttocks, stage three. A review of Patient 3's Plan of Care (POC) for the certification period of 04/18/2022 to 06/16/2022, indicated for the skilled nurse (SN) to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated the SN to perform a complete physical assessment each visit with emphasis on disease process. The POC further indicated the SN to assess the disease process of stage three pressure ulcer to the right heel, left heel, and right buttock. The POC indicated for the SN to check blood sugar and to instruct patient and primary caregiver diabetes. A review of Patient 3’s Skilled Nurse Visit/Progress Notes for the certification period of 04/18/2022 to 06/16/2022, indicated that there was only one nursing visit for the week of 04/24/2022 to 04/30/2022 and there was no documentation regarding the missed SN visits. During an interview with the DPCS 05/09/2022, at 12:22 p.m., he stated that the POC was created by him with the approval of the physician. The DPCS further stated that he made an error on Patient 3’s POC because the patient does not have diabetes and the POC should not have information regarding diabetes. DPCS stated that Patient 3 should have had two nurse visits on the week of 04/24/2022 to 04/30/2022 and he did not know why there was a missed visit because there was no communication note. d. A review of Patient 4's clinical record indicated a start of care date (SOC) of 03/15/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left buttock, stage three (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 4's Plan of Care (POC) for the certification period of 03/15/2022 to 05/13/2022, indicated for a skilled nurse (SN) to visit the patient for wound care every other day until 03/26/2022, then three times a week for 2 weeks and then two times a week for five weeks starting week of 03/27/2022. A review of Patient 4’s Communication Note dated 04/02/2022 at 12:00 a.m., indicated that there was a missed visit because there was no SN available. During an interview with the DPCS 05/09/2022 at 11:55 a.m., he stated that he was not informed regarding the missed visit and that there was no available nurse to visit the patient. The DPCS further stated that if there is no available nurse to visit a patient, then the agency would look for someone or he would go himself. e. A review of Patient 10's clinical record indicated a start of care date (SOC) of 05/03/2022, with diagnoses which included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and chronic kidney disease (gradual loss of kidney function). A review of Patient 10's Plan of Care (POC) for the certification period of 05/03/2022 to 07/01/2022, indicated for the skilled nurse (SN) to visit the patient two times a week for two weeks and then one time a week for seven weeks. A review of Patient 10’s clinical records indicated that there was only one nurse visit on the week 05/01/2022 to 05/07/2022 and there was no documentation regarding the missed visits. During an interview with the DPCS 05/09/2022 at 11:55 a.m., he stated that there was no communication note regarding Patient 1’s missed visits. The DPCS further stated that it was his responsibility to make sure the nursing visits are being done and that if there is a missed visit it should be documented. A review of the agency’s policy and procedure titled “Plan of Care – CMS #485 and Physician/Practitioner Orders,” dated 02/2021, indicated that the skilled nursing and other home health services will be in accordance with the plan of care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources. The policy and procedure further indicated that each patient must receive an individualized written plan of care, including any revisions or additions. Additionally, the policy and procedure further indicated that the individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the agency anticipates will occur as a result of implementing and coordinating the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to obtain a physician's order for the administration of Neosporin (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) topical ointment to the left heel pressure ulcer (areas of localized damage to the skin and underlying tissue) for one of 10 sampled patients (Patients 3). This deficient practice resulted in Neosporin being used on Patient 3’s left heel pressure ulcer without a physicians order and could result ineffective wound treatment. A review of Patient 3's clinical record indicated a start of care date (SOC) of 04/18/2022, with diagnoses which included pressure ulcer to the left and right heel, stage 3 (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and pressure ulcer to left and right buttocks, stage three. A review of Patient 3's Plan of Care (POC) for the certification period of 04/18/2022 to 06/16/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated, the SN has to perform a complete physical assessment each visit with emphasis on disease process. The POC further indicated, the SN has to assess the disease process of stage 3 pressure ulcer to the right heel, left heel, and right buttock. On 05/05/2022, at 10:55 p.m., a joint home visit with the Director of Patient Care Services (DPCS) was conducted at Patient 3’s residence. A review of Patient 3’s Medication Profile provided by the agency, indicated that patient has an order for wound care to the left heel. The order indicated to cleanse the left heel with normal saline (NS), pat dry, and cover with dry sterile dressing (DSD) daily. During a wound care observation by DPCS, Patient 3 was observed sitting on a chair and his left leg was elevated while DPCS was providing wound care. DPCS was observed cleaning the left heel pressure ulcer with NS and drying the wound with gauze. As DPCS was about to cover the wound with DSD, Patient 3’s Family Member, asked the DPCS, to put the Neosporin before covering with the bandage. Patient 3’s Family Member stated that LVN 8 had told her to get Neosporin and to apply it to patient’s left heel pressure ulcer during wound care. DPCS informed Patient 3’s Family Member that he would not be putting Neosporin on the patient’s left heel pressure ulcer and would clarify with LVN 8 because there was no physician order. DPCS then proceeded to wrap the left heel with DSD. During an interview with the DPCS on 05/05/2022 at 3:11 p.m., he stated that there was no physician order for Neosporin on Patient 3’s left heel pressure ulcer. DPCS further stated that a nurse has to inform the physician to start and administer new medication. Additionally, the DPCS stated, a written order from the physician has to be in place before starting a new medication. A review of the agency’s policy and procedure titled “Plan of Care – CMS #485 and Physician/Practitioner Orders,” dated 02/2021, indicated that all patient care orders, including verbal orders, must be recorded in the plan of care. The policy and procedure further indicated that the plan will be revised to reflect any verbal order received during the 60-day certification period so that all agency staff are working from a current plan.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure Quality Assessment and Performance Improvement (QAPI) program on the year 2021, that included procedure for measurement and analysis of indicators and address the frequency which measurement and analysis. This deficiency practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality of care. During a concurrent interview and record review on 5/6/2022 at 10:55 a.m. with Administrator (ADM) of facility’s QAPI folder, the folder indicated there was no documentation for a QAPI program for 2021. ADM stated, “To be honest we don’t have a QAPI for 2021. No governing body minutes or QAPI for 2021. We are expecting you (referring to the survey team) next year”. Review of facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program revised March 2018 indicated that the Home Health Agency (HHA) continuously collect and analyze data to improve Agency’s performance of clinical and other processes…

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide documented evidence the HHA's governing body approved the frequency and detail of the data collection done by the HHA's 2021 Quality Assessment and Performance Improvement (QAPI) program. This deficiency practice resulted in the inability of the agency to monitor the effectiveness and safety services and quality of care and identify opportunities of improvements. During a concurrent interview and record review on 5/6/2022 at 10:55 a.m. with Administrator (ADM) of facility’s QAPI folder, the folder indicated there was no documentation for a QAPI program for 2021. ADM stated, “To be honest we don’t have a QAPI for 2021. No governing body minutes or QAPI for 2021. We are expecting you next year”. Review of facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program revised March 2018 indicated that the Home Health Agency (HHA) continuously collect and analyze data to improve Agency’s performance of clinical and other processes…

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) 2021 Quality Assessment and Performance Improvement (QAPI) program failed to provide documented evidence of the QAPI program that focuses on high risk, high volume, or problem-prone areas. This deficient practice resulted in the inability of the agency to identify the problems, prevent the re-occurring, and make improvement During a concurrent interview and record review on 5/6/2022, at 10:55 a.m., with Administrator (ADM) of facility’s QAPI folder, the folder indicated there was no documentation for a QAPI program for 2021. ADM stated, “To be honest we don’t have a QAPI for 2021. No governing body minutes or QAPI for 2021. We are expecting you next year”. Review of facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program revised March 2018 indicated that the Home Health Agency (HHA) continuously collect and analyze data to improve Agency’s performance of clinical and other processes…

Incidence, prevalence, severity of problems CFR(s): 484.65(c)(1)(ii) (ii) Consider incidence, prevalence, and severity of problems in those areas; and This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) 2021 Quality Assessment and Performance Improvement (QAPI) program failed to provide documented evidence identifying incidence, prevalence, and severity of problem areas. This deficient practice had the potential to cause negative events which may result in the decline in patient's conditions. Findings: During a concurrent interview and record review on 5/6/2022, at 10:55 a.m., with Administrator (ADM) of facility’s QAPI folder, the folder indicated there was no documentation for a QAPI program for 2021. ADM stated, “To be honest we don’t have a QAPI for 2021. No governing body minutes or QAPI for 2021. We are expecting you next year”. Review of facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program revised March 2018 indicated that the Home Health Agency (HHA) continuously collect and analyze data to improve Agency’s performance of clinical and other processes…

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) 2021 Quality Assessment and Performance Improvement (QAPI) failed to measure success and track performance to ensure that improvements were sustained. This deficient practice had the potential to cause negative and unexpected events that impact a patient's plan of care which may cause a decline in a patient's condition. Findings: During a concurrent interview and record review on 5/6/2022 at 10:55 a.m. with Administrator (ADM) of facility’s QAPI folder, the folder indicated there was no documentation for a QAPI program for 2021. ADM stated, “To be honest we don’t have a QAPI for 2021. No governing body minutes or QAPI for 2021. We were expecting you next year”. Review of facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program revised March 2018 indicated that the Home Health Agency (HHA) continuously collect and analyze data to improve Agency’s performance of clinical and other processes…

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 interview and record review, the Home Health Agency (HHA) governing body failed to execute their responsibilities to ensure: (1) An ongoing program for quality improvement and patient safety is defined, implemented, and maintained. (2) 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) Clear expectations for patient safety are established, implemented, and maintained. (4) Findings of fraud or waste are appropriately addressed. These failures had the potential for the patients' care needs will not be met that could affect their quality of care and quality of life. Findings: During a concurrent interview and record review on 5/6/2022, at 10:55 a.m., with Administrator (ADM) of facility’s QAPI folder, the folder indicated there was no documentation for a QAPI program for 2021. ADM stated, “To be honest we don’t have a QAPI for 2021. No governing body minutes or QAPI for 2021. We are expecting you next year”. Review of facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program revised March 2018 indicated that the Home Health Agency (HHA) continuously collect and analyze data to improve Agency’s performance of clinical and other processes…

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: This condition is not met as evidence by: Based on interview and record review the home health agency (HHA) failed to develop and implement its policy and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) infection control on employees’ vaccination requirements, for 29 out of 30 agency employees and 216 patients. The agency failed to: 1. Have a process for ensuring that all 30 required agency employees (who provide any care, treatment or other services for the HHA and/or its patients) were fully vaccinated; 2. Develop and implement a policy and procedures to monitor employees’ COVID-19 vaccinations status; 3. Ensure a process for tracking and securely documenting the COVID-19 vaccination status or proof of vaccination for all required employees including the percentage of unvaccinated staff, excluding those staff that have approved exemptions; 4. Ensure a process that all documentation, which confirms, recognized contraindications to COVID-19 vaccines, and which supports employees’ requests for medical exemptions from vaccination; 5. Have a process for ensuring all staff obtain any recommended booster doses, and any recommended additional doses for individuals who are immunocompromised, in accordance with the recommended timing of such doses; 6. Have a process by which staff may request a vaccine exemption from the COVID-19 vaccination requirements based on recognized clinical contraindications or applicable Federal laws, such as religious beliefs or other accommodations; 7. Have a process for ensuring the tracking and securing the documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the Centers for Disease Control and Prevention (CDC); 8. Ensure contingency plans for employees that were not vaccinated for COVID-19 (and without an exemption for medical contraindications or without a temporary delay in vaccination due to clinical considerations). 9. Have a process for ensuring that the HHA continues to follow all standards of infection prevention and control practice, for reducing the transmission and spread of COVID-19 in the HHA, especially by those staff who are unvaccinated or who are not yet fully vaccinated. 10. Ensure that all required employees had N 95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit test, as indicated in the CDC. (Refer to G687). The cumulative effect of these systemic problems resulted in the HHA's inability to ensure the provision of quality health care in a safe environment, had the potential to result in placing patients and employees at risk for spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization and/or death. Refer to G687

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to develop and implement its policy and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) infection control on employees’ vaccination requirements, for 29 out of 30 agency employees and 216 patients. The agency failed to: 1. Have a process for ensuring that all 30 required agency employees (who provide any care, treatment or other services for the HHA and/or its patients) were fully vaccinated; 2. Develop and implement a policy and procedures to monitor employees’ COVID-19 vaccinations status; 3. Ensure a process for tracking and securely documenting the COVID-19 vaccination status or proof of vaccination for all required employees including the percentage of unvaccinated staff, excluding those staff that have approved exemptions; 4. Ensure a process that all documentation, which confirms, recognized contraindications to COVID-19 vaccines, and which supports employees’ requests for medical exemptions from vaccination; 5. Have a process for ensuring all staff obtain any recommended booster doses, and any recommended additional doses for individuals who are immunocompromised, in accordance with the recommended timing of such doses; 6. Have a process by which staff may request a vaccine exemption from the COVID-19 vaccination requirements based on recognized clinical contraindications or applicable Federal laws, such as religious beliefs or other accommodations; 7. Have a process for ensuring the tracking and securing the documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the Centers for Disease Control and Prevention (CDC); 8. Ensure contingency plans for employees that were not vaccinated for COVID-19 (and without an exemption for medical contraindications or without a temporary delay in vaccination due to clinical considerations). 9. Have a process for ensuring that the HHA continues to follow all standards of infection prevention and control practice, for reducing the transmission and spread of COVID-19 in the HHA, especially by those staff who are unvaccinated or who are not yet fully vaccinated. 10. Ensure that all required employees had N 95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit test, as indicated in the CDC. These deficient practices had the potential to result in placing patients and employees at risk for spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization and/or death. Findings: On 5/10/2022 at 5:16 p.m., an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the agency’s Administrator (ADM) and the Chief Executive Officer (CEO) for the facility’s failure to ensure COVID-19 policies and procedures were developed and implemented. On 5/11/2022 at 4:39 p.m., the IJ was removed after the agency submitted an IJ Removal Plan in the presence of the ADM and the agency office staff. The survey team verified and confirmed during onsite, the implementation of the removal plan, through interviews and record review. The accepted IJ Removal Plan included the following actions: 1. An immediate review and tracking of all staff of their vaccination records. The HHA tracked all staff vaccination records. The Director of Patient Client Services (DPCS), will review all staff COVID 19 vaccination records 2. The HHA, developed a contingency plan for unvaccinated staff. The DPCS developed a contingency plan, included, the availability of vaccinated staff to do the patient home visits, 3. Updated policies and procedures for employees who have contracted COVID-19. The HHA updated policy will include, that the exposed office staff will be tracked and tested. 4. Copies of employee COVID-19 vaccination and booster cards. On 5/11/2022 a copies of the staff COVID 19 vaccination record were provided. 5. COVID-19 in-services. On 5/11/2022 the DPCS conducted an in service to the office staff and will be on going. Findings: A review of the agency’s census during the recertification survey on 5/4/2022 indicated, the home health agency (HHA) was actively caring for 219 patients. During an interview on 5/4/2022 at 3:03 p.m. with Administrator (ADM), ADM stated the agency has no records of COVID-19 vaccination record for their staff and has no records of the unvaccinated staff. ADM stated that all HHA staff have received their vaccinations, including a booster, but could not provide a records of the staff COVID 19 vaccination. During an interview on 5/9/2022 at 3:53 p.m. with ADM, ADM stated that he logs onto the Centers for Medicate & Medical Services (CMS) website to inquire of any COVID-19 updates every 2-3 months. ADM stated last time he was on the website was in December 2021. ADM stated that as far as he knew they were not instructed on keeping the employees COVID-19 vaccination list. The ADM stated that the HHA employee had no N95 mask fit test. ADM stated that he did not know how to perform a seal check on an N95 mask. The ADM stated, the agency would train the employees for N95 fit test in the next in service. During the interview, the ADM stated, that Registered Nurse 7 (RN7) tested positive for COVID-19 on 5/4/2022 and was immediately had to isolate. A review of HHA’s undated COVID-19 monitoring sheet, indicated, last entry was on 01/18/2021. During an interview on 5/10/2022 at 10:20 a.m. with ADM, ADM stated, “There is no sign-in sheet, they just go to the particular person and hand over their notes”, when asked for the COVID-19 monitoring staff sign in sheet. ADM stated that there was a sign-in sheet during “the height of the pandemic” but has not been used since 1/18/2021, when the last entry was made. During an interview on 5/10/2022 at 1:10 p.m. with ADM, ADM stated the HHA had no written policy and procedures for staff COVID-19 monitoring or a policy on the steps to take if a staff becomes exposed to COVID-19. During an interview on 5/10/2022 at 1:15 p.m., ADM stated that RN7 had a COVID-19 test due to not feeling well on 5/4/2022. The ADM stated, that RN7 made a home visit to Patient 10 on 5/3/2022. ADM stated that on 5/9/2022, the assisted living facility Patient 10 resides at has been notified of RN7’s positive result of COVID 19. A review of Patient 10's clinical record indicated a start of care date (SOC) of 05/03/2022, with diagnoses which included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and chronic kidney disease (gradual loss of kidney function). A review of the undated HHA’s “COVID Vaccine Card” indicated that there were 20 out of 30 employees that have no proof of receiving the COVID19 vaccine, with percentage of unvaccinated employees was 74%. There were six RNs, nine, LVNs, and five certified home health aides that had no proof of receiving the COVID-19 vaccine. A review of the undated HHA’s policy titled, “Infection Control Measures for COVID-19” indicated, Home Health (HH) will ensure COVID-19 vaccine requirements are followed. The policy and procedure did not address procedures for COVID-19 vaccination of the staff, vaccination exemption, tracking and documenting vaccination status, ensuring all staff obtain any recommendation, booster doses, and any recommended additional doses for individuals who are immunocompromised, tracking and securely documenting information confirming recognized clinical contraindications to COVID-19 vaccines, and contingency plan for unvaccinated staff and to mitigate the spread of COVID-19 infection. A review of Centers for Disease Control and Prevention on COVID-19 vaccines indicated COVID-19 vaccines are effective at protecting people from getting seriously ill, being hospitalization, and dying. COVID-19 vaccination lowers the risk of severe illness, hospitalization, and death. Unvaccinated people are more likely to get COVID-19, much more likely to be hospitalized with COVID-19, and much more likely to die from COVID-19. According to Center for Disease Control and Prevention (CDC), https://www.cdc.gov/ The Occupational Safety and Health Administration (OSHA) (29 CFR 1910.134) requires respirator users to be fit tested to confirm the fit of any respirator that forms a tight seal on your face before using it in the workplace. Fit testing is important to ensure the expected level of protection is provided by minimizing the total amount of contaminant leakage into the facepiece through the face seal… Occupational Safety and Health Administration (OSHA) respirator fit testing requirement, both annually and when physical changes have occurred.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health agency (HHA) agency failed to ensure the Condition of Participation regarding Skilled Professional Services was met as follows: 1. The HHA failed to ensure the skilled nurse (SN) assessed the skin and notify the physician regarding increased blood sugar and change of condition for one of 10 patients (Patients 1). Refer to G 704 2. The HHA failed to follow the Plan of Care (POC) one of 10 patients (Patients 1). Refer to G 710 3. The HHA failed to provide in-service to their licensed staff. Refer to G722 4. The HHA failed to ensure nursing services are provided under the supervision of a Registered Nurse (RN) for nine of 10 patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, and 9). Refer to G 726 The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the skilled nurse (SN), during each visit to the patient, conduct skin assessment and status of the patient's pressure ulcer (areas of localized damage to the skin and underlying tissue), notify the physician when the patient's blood sugar level result 380 milligrams per deciliter (mg/dl, unit of measurement), and the patient's significant change of condition for one of 10 sampled patients (Patient 1). The deficient practice resulted in the patient's high blood glucose level, lack of treatment to pressure ulcer, and patient's hospitalization. A review of Patient 1's clinical record indicated a start of care date (SOC) of 02/10/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and Type II diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 02/10/2022 to 04/10/2022, indicated for the skilled nurse (SN) to visit patient two times a week for one weeks, then three times a week for two weeks, then two times a week for two weeks and then one time a week for four weeks. The POC indicated for the SN to perform blood sugar check, weigh Patient 1 every visit, and document. The POC further indicated the for the SN to perform a complete physical assessment each visit with emphasis on disease process. The POC indicated for the SN to report to the physician any significant changes in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl– unit if measurement). A review of Patient 1’s Communication Note dated 02/10/2022 at 4:02 p.m., indicated SN called the agency to report the patient refused to turn for skin assessment on the back area and buttocks area. The communication note did not indicate that Patient 1 refused skin assessments on her legs. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/14/2022, indicated that SN assessed patient’s skin integrity from head to toe and patient refused thorough body assessment of the back. The Skilled Nurse Visit/Progress Note indicated that patient had right and left heel diabetic ulcers. The Skilled Nurse Visit/Progress Note further indicated that Patient 1’s blood sugar was checked, and the reading was 380 mg/dl. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/16/2022, indicated that SN checked patient’s blood sugar and the reading was 375 mg/dl. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/19/2022, indicated that SN did skin assessment, but patient refused to turn to check the back area and sacral area. The Skilled Nurse Visit/Progress Note further stated that the patient tolerated the wound care well and no signs and symptoms of infection noted. A review of Patient 1’s Communication Note dated 02/19/2022 at 1:05 p.m., indicated that SN called the agency to report that the patient noted with right lower extremities with purplish in color. A review of Patient 1’s Communication Note dated 02/21/2022 at 12:00 a.m., indicated that SN called the agency to report that patient was admitted to the General Acute Care Hospital (GACH) due to generalized weakness. During an interview with the Registered Nurse (RN 6) at 05/09/2022, at 1:42 p.m., she stated that Patient 1 refused to get her back assessed but that she was able to assess her legs and she did not see anything. During an interview with the DPCS 05/09/2022, at 3:05 p.m., he stated that a head-to-toe assessment is conducted every visit and if patient refuses then it is documented, and physician is notified. The DPCS stated that the physician was notified on 02/10/2022 regarding Patient 1’s refusal to get her back assessed but physician was not notified on 02/14/2022 and 02/16/2022. The DPCS further stated that if a patient’s blood sugar is outside parameters the nurse is supposed to notify the agency and the physician. The DPCS stated that LVN 12 did not notify the physician or the agency regarding Patient 1’s blood sugar being outside the parameters on 02/14/2022 and 02/16/2022. During an interview with the Licensed Vocational Nurse (LVN 12) at 05/10/2022, at 11:36 a.m., she stated that Patient 1 refused to get her back assessed but she was able to assess her legs and that there was nothing on the legs. LVN 12 stated that she did not report to the physician regarding Patient 1’s blood sugar on 2/14/2022 and 02/16/2022 but she did report to LVN 4. LVN 12 further stated that she did not document that she reported Patient 1’s blood sugar to LVN 4. During an interview with the Licensed Vocational Nurse (LVN 4) at 05/10/2022, at 1:26 p.m., he stated that he was also the case manager and that he resigned from the agency on 04/25/2022. LVN 4 stated that when a patient has a change of condition or refuses care then the nurse should document and notify the physician. LVN 4 stated that she did not remember LVN 12 notifying him regarding Patient 1’s blood sugar on 02/14/2022 and 02/16/2022. LVN 4 further stated that if LVN 12 did notify him regarding Patient 1’s blood sugar being high then he would have documented it. A review of Patient 1’s GACH records indicated that patient was admitted on 02/21/2022 and admitted to the Intensive Care Unit (ICU) for management of diabetic ketoacidosis (DKA - serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones) and sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) secondary to pyelonephritis (urinary tract infection where one or both kidneys become infected)/pressure wounds. The GACH records further indicated that Patient 1 had stage three pressure ulcer (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) to the right hip, right posterior (back) superior (upper) lower leg, right lateral(away from the midline of the body) inferior(lower) lower leg, right lateral lower leg, left buttocks, and left superior buttocks. Additionally, the GACH records indicated that Patient 1 had an unstageable pressure ulcer to the sacrum, right heel, and left heel. A review of Patient 1’s Physician Order dated 03/02/2022, at 8: 41 a.m., indicated Patient 1 passed away while at the hospital and to discharge patient from home health services. A review of the agency’s Job Description “Registered Nurse (RN),” dated 03/2018, indicated that the responsibility of an RN includes providing services in accordance with the plan of care, initiate plan of care and make necessary revisions, coordinate services, and process orders and notifies the physician of patient needs and change of condition. A review of the agency’s Job Description “Licensed Practical/Vocational Nurse (LPN/LVN),” dated 03/2018, indicated that the responsibility of an LVN includes implementing the nursing care plan for each patient, provide nursing services, treatments and diagnostics and preventive procedures as assigned, observe signs and symptoms and report to the physician and RN reaction to treatments, including drugs and changes in the patient’s physical or emotional condition, and maintain accurate and complete records of observation, treatments and care of patient.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to follow the Plan of Care (POC) for one of 10 sampled patients (Patients 1). The agency failed to ensure, the Skilled Nurse (SN), conduct an assessment on the patient's skin status and pressure ulcer on each home visit and did not notify the physician when the patient's blood glucose (blood sugar) level was 380 mg/dl. The deficient practice had the potential to affect the patient’s progress to meet the patient care goals. A review of Patient 1's clinical record indicated a start of care date (SOC) of 02/10/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and Type II diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 02/10/2022 to 04/10/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week for one weeks, then three times a week for two weeks, then two times a week for two weeks and then one time a week for four weeks. The POC indicated that the SN is to perform blood sugar check and weigh Patient 1 every visit and document. The POC further indicated that the SN is to perform a complete physical assessment each visit with emphasis on disease process. The POC indicated that the SN is to report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of Patient 1’s Communication Note dated 02/10/2022 at 4:02 p.m., indicated that SN called the agency to report that patient refused to turn for skin assessment on the back area and buttocks area. The communication note did not indicate that Patient 1 refused skin assessments on her legs. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/14/2022, indicated that SN assessed patient’s skin integrity from head to toe and patient refused thorough body assessment of back. The Skilled Nurse Visit/Progress Note indicated that patient had right and left heel diabetic ulcers. The Skilled Nurse Visit/Progress Note further indicated that Patient 1’s blood sugar was checked, and the reading was 380. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/16/2022, indicated that SN checked patient’s blood sugar and the reading was 375. The Skilled Nurse Visit/Progress Note further indicated that SN assessed patient. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/19/2022, indicated that SN did skin assessment, but patient refused to turn to check the back area and sacral area. The Skilled Nurse Visit/Progress Note further stated that the patient tolerated the wound care well and no signs and symptoms of infection noted. A review of Patient 1’s Communication Note dated 02/19/2022 at 1:05 p.m., indicated that SN called the agency to report that the patient noted with right lower extremities with purplish in color. A review of Patient 1’s Communication Note dated 02/21/2022 at 12:00 a.m., indicated that SN called the agency to report that patient was admitted to the General Acute Care Hospital (GACH) due to generalized weakness. During an interview with the Registered Nurse (RN 6) at 05/09/2022 at 1:42 p.m., she stated that Patient 1 refused to get her back assessed but that she was able to assess her legs and she did not see anything. During an interview with the DPCS 05/09/2022 at 3:05 p.m., he stated that a head-to-toe assessment is conducted every visit and if patient refuses then it is documented, and physician is notified. The DPCS stated that the physician was notified on 02/10/2022 regarding Patient 1’s refusal to get her back assessed but physician was not notified on 02/14/2022 and 02/16/2022. The DPCS further stated that if a patient’s blood sugar is outside parameters the nurse is supposed to notify the agency and the physician. The DPCS stated that LVN 12 did not notify the physician or the agency regarding Patient 1’s blood sugar being outside the parameters on 02/14/2022 and 02/16/2022. During an interview with the Licensed Vocational Nurse (LVN 4) at 05/10/2022 at 1:26 p.m., he stated that he was also the case manager and that he resigned from the agency on 04/25/2022. LVN 4 stated that when a patient has a change of condition or refuses care then the nurse should document and notify the physician. LVN 4 stated that she does not remember LVN 12 notifying him regarding Patient 1’s blood sugar on 02/14/2022 and 02/16/2022. LVN 4 further stated that if LVN 12 did notify him regarding Patient 1’s blood sugar being high then he would have documented it. During an interview with the Licensed Vocational Nurse (LVN 12) at 05/10/2022 at 11:36 a.m., she stated that Patient 1 refused to get her back assessed but she was able to assess her legs and that there was nothing on the legs. LVN 12 stated that she did not report to the physician regarding Patient 1’s blood sugar on 2/14/2022 and 02/16/2022 but she did report to LVN 4. LVN 12 further stated that she did not document that she reported Patient 1’s blood sugar to LVN 4. A review of the agency’s policy and procedure titled “Plan of Care – CMS #485 and Physician/Practitioner Orders,” dated 02/2021, indicated that each patient must receive an individualized written plan of care, including any revisions or additions. The policy and procedure further indicated that the individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the agency anticipates will occur as a result of implementing and coordinating the plan of care. Additionally, the policy and procedure further indicated that if the patient or the patient’s representative refuses care that could impact the patient’s clinical wellbeing on more than one occasion, then the agency must attempt to identify reason for refusal and if agency is unable to identify and address the reason for the refusal, then the agency must communicate with the patient’s responsible physician/practitioner to discuss how to proceed with patient care.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide in-services to all licensed staffs. This deficient practice resulted in the HHA’s licensed staffs lack of knowledge to provide or perform the highest quality of patient care services. On 05/04/2022, a review of the agency’s in-service was conducted. The 2021 licensed nurse in-service log was requested from the Director of Patient Care Services (DPCS). During an interview with the DPCS on 05/04/2022, at 1:45 p.m., he stated that there were no in-services conducted in 2021 for the licensed staffs. A review of the agency’s policy and procedure titled “Inservice Education,” dated 02/2021, indicated that regularly scheduled and appropriate in-service programs will be made available for all employees. The policy and procedure further indicated that the purpose is to ensure the continuing education of all agency personnel. Additionally, the policy and procedure indicated that direct care personnel must have a minimum of 12 hours of ongoing education during each 12-month period.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health agency (HHA) failed to ensure nursing services are under the supervision of a Registered Nurse (RN) for nine of 10 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9). The deficient practice has the potential for the nursing care performance towards the patients will not be monitored or evaluated that could affect the provision of patient care and patient's well being. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 02/10/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 02/10/2022 to 04/10/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week for one weeks, then three times a week for two weeks, then two times a week for two weeks and then one time a week for four weeks. The POC indicated that the SN is to perform blood sugar check and weigh Patient 1 every visit and document. The POC further indicated that the SN is to perform a complete physical assessment each visit with emphasis on disease process. Additionally, the POC indicated that the SN is to report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/19/2022, with diagnoses which included type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 2's Plan of Care (POC) for the certification period of 03/20/2022 to 05/18/2022, indicated that a skilled nurse (SN) is scheduled to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated that the SN is to perform blood sugar and oxygen saturation every visit. POC further indicated that the SN is to report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). c. A review of Patient 3's clinical record indicated a start of care date (SOC) of 04/18/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, stage three (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and pressure ulcer to left and right buttocks, stage three. A review of Patient 3's Plan of Care (POC) for the certification period of 04/18/2022 to 06/16/2022, indicated that a skilled nurse (SN) is scheduled to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated that the SN is to perform a complete physical assessment each visit with emphasis on disease process. The POC further indicated that the SN is to assess the disease process of stage three pressure ulcer to the right heel, left heel, and right buttock. d. A review of Patient 4's clinical record indicated a start of care date (SOC) of 03/15/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left buttock, stage three (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 4's Plan of Care (POC) for the certification period of 03/15/2022 to 05/13/2022, indicated that a skilled nurse (SN) is scheduled to visit the patient for wound care every other day until 03/26/2022, then three times a week for 2 weeks and then two times a week for five weeks starting week of 03/27/2022. e. A review of Patient 5’s “Patient Demographic” indicated Patient 5 was admitted on 11/24/2021 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and Cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right lower limb. A review of Patient 5’s “Home Health Certification and Plan of Care” (POC) dated 11/24/2021 to 01/22/2022 indicated Patient 5 had Skilled Nursing (SN) visits ordered twice a week for one week then, three times a week for eight weeks. Patient 5 also had Certified Home Health Aide (CHHA) visits for twice a week for nine weeks. The POC also indicated Patient 5 was oriented. f. A review of Patient 6’s “Patient Demographic” indicated Patient 6 was admitted on 11/2/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). A review of Patient 6’s “Plan of Care” dated 3/2/2022 – 4/30/2022 indicated Patient 6 was oriented and forgetful. Patient 6 had Skilled Nursing visits ordered once a week for nine weeks. SN to perform at every visit: vital signs, blood sugar, weight, and document, and 02 saturation reading. g. A review of Patient 7’s “Patient Demographic” indicated Patient 7 was admitted on 4/2/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). A review of Patient 7’s “Home Health Certification and Plan of Care” (POC) dated 4/2/2022 to 5/31/2022 indicated Patient 7 had Skilled Nursing (SN) visits ordered once a week for one week then, twice a week for two weeks then, once a week for six weeks. The POC also indicated Patient 7 was oriented. h. A review of Patient 8’s “Patient Demographic” indicated Patient 8 was admitted on 10/1/2021 with a diagnosis of Guillain-Barre Syndrome (a rare disorder in which your body's immune system attacks your nerves) and Pressure Ulcer of left buttocks, stage II (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). A review of Patient 8’s “Home Health Certification and Plan of Care” (POC) dated 3/30/2022 – 5/28/2022 indicated Patient 8 had Skilled Nursing (SN) visit for twice a week for 2 weeks then, once a week for seven weeks. The POC also indicated Patient 8 was alert, oriented, able to focus and shift attention, comprehensive and recalls task directions independently. i. A review of Patient 9’s “Patient Demographic” indicated Patient 9 was admitted on 1/28/2022 with a diagnosis of Cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain) and Dysphagia (difficulty or discomfort in swallowing). A review of Patient 9’s “Home Health Certification and Plan of Care” (POC) dated 3/29/2022 – 5/27/2022 indicated Patient 9 had Skilled Nursing (SN) visit for one time per week for nine weeks and Certified Home Health Assistant (CHHA) visit for one times per week for nine weeks. The POC also indicated Patient 9 was oriented. During an interview and a concurrent record review with the DPCS on 05/09/2022 at 11:45 a.m., he stated that there were no licensed vocational nurse (LVN) supervisory visit notes conducted by the RN for Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9 since their start of care dates. The DPCS further stated LVN supervisory visits should be done at least every 30 days and that he should be the one to conduct them because he is the RN. A review of the agency’s policy and procedure titled “Nursing Services,” dated 02/2021, indicated that the LVN will be supervised by the RN as required by applicable state rules and regulations.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that at least 12 hours of in-service during a 12-month period was given to six of six Certified Home Health Aides (CHHA 1, CHHA 2, CHHA 3, CHHA 4, CHHA 5, and CHHA 6). This deficient practice has the potential risk for the CHHA to lack updated knowledge and skills to provide highest quality of patient care services. On 05/04/2022, a review of the agency’s CHHA in-services was conducted. The 2021 CHHA in-service log was requested from the Director of Patient Care Services (DPCS). During an interview with the DPCS on 05/04/2022, at 1:45 p.m., he stated that there were no in-services conducted in 2021 for the CHHA. A review of the agency’s policy and procedure titled “Home Health Aide Services and Training Program,” dated 02/2021, indicated that a home health aides must receive at least 12 hours of in-service training during each 12-month period. The policy and procedure further indicated that the agency must maintain documentation that demonstrates the requirements of this standard have been met.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health agency (HHA) agency failed to ensure the Condition of Participation for Organization and Administration of Services was met as follows: 1. The HHA governing body failed to execute their responsibilities for the agency's overall management and operation and provision of home health services by failing to: a. Ensure the skilled nurse (SN), during each visit to the patient, implemented the plans of care (POC) for two of 10 sampled patients (Patients 1 and 2) on performing skin assessment and status of the patient's pressure ulcer (areas of localized damage to the skin and underlying tissue), notifying the physician when the patient's blood sugar level result 380 milligrams per deciliter (mg/dl, unit of measurement), and the patient's significant change of condition, and checking the patient's oxygen saturation (amount of oxygen circulating in the blood and normal saturation levels are 95-100 percent) (Refer to G 942). 2. The HHA failed to have qualified personnel by failing to: a. Ensure one of 28 staff (Licensed Vocational Nurse 9 [LVN 9]) had the required experience to work for the agency. b. Ensure five of 28 staff (Registered Nurse (RN) RN5, RN6, LVN1, LVN3, LVN5) had updated History and Physical examinations. c. Ensure three of 28 staff (RN1, RN5, and RN6) had updated Basic Life Support Certificates. d. Ensure one of 28 staff (RN6) had a resume. e. Ensure two of 28 staff ( RN6 and LVN9) had a completed work application. f. Ensure six of 28 staff (RN5, RN6, RN7, LVN1, LVN3, and LVN5) had an updated Purified Protein Derivative (PPD) skin test (test that determines if you have tuberculosis [serious lung infection]). g. Ensure six of 28 staff ( RN7, LVN2, LVN9, LVN12, Intake Coordinator, and Quality Assurance Assistant) received agency orientation. h. Ensure one of 28 staff (LVN12) had an education/employment background check. i. Ensure two of 28 staff (LVN9 and LVN12) had a competency review (Refer to G 952). The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care services in a safe environment. Refer to G 942 Refer to G 952

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) governing body failed to execute their responsibilities for the agency's overall management and operation and provision of home health services by failing to: 1. Ensure the skilled nurse (SN), during each visit to the patient, implemented the plans of care (POC) for two of 10 sampled patients (Patients 1 and 2) on performing skin assessment and status of the patient's pressure ulcer (areas of localized damage to the skin and underlying tissue), notifying the physician when the patient's blood sugar level result 380 milligrams per deciliter (mg/dl, unit of measurement), and the patient's significant change of condition, and checking the patient's oxygen saturation (amount of oxygen circulating in the blood and normal saturation levels are 95-100 percent). The deficient practice resulted in Patient 1's high blood glucose level not monitored, lack of assessment and treatment to pressure ulcers, and patient's hospitalization. A review of the agency’s governing body minutes dated 04/29/2022, indicated that there was no documentation regarding a discussion about staff reporting any issues or change of condition during patient care to the physician and the need for further education to the staff. During a concurrent interview and record review on 5/6/2022, at 10:55 a.m., with Administrator (ADM) of facility’s QAPI folder, the folder indicated there was no documentation for a QAPI program for 2021. ADM stated, “To be honest we don’t have a QAPI for 2021. No governing body minutes or QAPI for 2021. We are expecting you next year.” A review of the agency’s policy and procedure titled “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” dated 02/2021, indicated that the governing body is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented, and maintained. The policy and procedure further indicated that the governing body takes actions that address the agency’s performance across the spectrum of care, including the prevention and reduction of medical errors. Additionally, the policy and procedure further indicated that the governing body addresses priorities for improved quality of care and safety. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 02/10/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and Type II diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 02/10/2022 to 04/10/2022, indicated for the skilled nurse (SN) to visit patient two times a week for one weeks, then three times a week for two weeks, then two times a week for two weeks and then one time a week for four weeks. The POC indicated the SN to perform blood sugar check and weigh Patient 1 every visit and document. The POC further indicated SN to perform a complete physical assessment each visit with emphasis on disease process. The POC indicated the SN was to report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of Patient 1’s Communication Note dated 02/10/2022 at 4:02 p.m., indicated SN called the agency to report that patient refused to turn for skin assessment on the back area and buttocks area. The communication note did not indicate that Patient 1 refused skin assessments on her legs. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/14/2022, indicated that SN assessed patient’s skin integrity from head to toe and patient refused thorough body assessment of back. The Skilled Nurse Visit/Progress Note indicated that patient had right and left heel diabetic ulcers. The Skilled Nurse Visit/Progress Note further indicated that Patient 1’s blood sugar was checked, and the reading was 380 (normal blood sugar level is between 72 mg/dL and 108 mg/dL). A review of Patient 1's Skilled Nurse Visit/Progress Note dated 02/16/2022, indicated that SN checked patient’s blood sugar and the reading was 375. The Skilled Nurse Visit/Progress Note further indicated that SN assessed patient. A review of Patient 1’s Skilled Nurse Visit/Progress Note dated 02/19/2022, indicated that SN did skin assessment, but patient refused to turn to check the back area and sacral area. The Skilled Nurse Visit/Progress Note further stated that the patient tolerated the wound care well and no signs and symptoms of infection noted. A review of Patient 1’s Communication Note dated 02/19/2022 at 1:05 p.m., indicated that SN called the agency to report that the patient's right lower extremities was noted with purplish in color. A review of Patient 1’s Communication Note dated 02/21/2022 at 12:00 a.m., indicated that SN called the agency to report that patient was admitted to the General Acute Care Hospital (GACH) due to generalized weakness. During an interview with the Registered Nurse (RN 6) at 05/09/2022 at 1:42 p.m., she stated that Patient 1 refused to get her back assessed but that she was able to assess her legs and she did not see anything. During an interview with the DPCS 05/09/2022 at 3:05 p.m., he stated that a head-to-toe assessment was to be conducted every visit and if patient refused then it should be documented, and physician was to be notified. The DPCS stated that the physician was notified on 02/10/2022 regarding Patient 1’s refusal to get her back assessed but physician was not notified on 02/14/2022 and 02/16/2022. The DPCS further stated that if a patient’s blood sugar is outside parameters the nurse is supposed to notify the agency and the physician. The DPCS stated that LVN 12 did not notify the physician or the agency regarding Patient 1’s blood sugar being outside the parameters on 02/14/2022 and 02/16/2022. During an interview with the Licensed Vocational Nurse (LVN 4) at 05/10/2022 at 1:26 p.m., he stated that he was also the case manager and that he resigned from the agency on 04/25/2022. LVN 4 stated that when a patient has a change of condition or refuses care then the nurse should document and notify the physician. LVN 4 stated that she does not remember LVN 12 notifying him regarding Patient 1’s blood sugar on 02/14/2022 and 02/16/2022. LVN 4 further stated that if LVN 12 did notify him regarding Patient 1’s blood sugar being high then he would have documented it. During an interview with the Licensed Vocational Nurse (LVN 12) at 05/10/2022 at 11:36 a.m., she stated that Patient 1 refused to get her back assessed but she was able to assess her legs and that there was nothing on the legs. LVN 12 stated that she did not report to the physician regarding Patient 1’s blood sugar on 2/14/2022 and 02/16/2022 but she did report to LVN 4. LVN 12 further stated that she did not document that she reported Patient 1’s blood sugar to LVN 4. A review of Patient 1’s Physician Order dated 03/02/2022 at 8: 41 a.m., indicated that patient passed away while at the GACH and to discharge patient from home health services. A review of Patient 1’s GACH records indicated that patient was admitted on 02/21/2022 and admitted to the Intensive Care Unit (ICU) for management of diabetic ketoacidosis (DKA - serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones) and sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) secondary to pyelonephritis (urinary tract infection where one or both kidneys become infected)/pressure wounds. The GACH records further indicated that Patient 1 had stage three pressure ulcer (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) to the right hip, right posterior (back) superior (upper) lower leg, right lateral (away from the midline of the body) inferior (lower) lower leg, right lateral lower leg, left buttocks, and left superior buttocks. Additionally, the GACH records indicated that Patient 1 had an unstageable pressure ulcer to the sacrum, right heel, and left heel. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/19/2022, with diagnoses which included type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 2's Plan of Care (POC) for the certification period of 03/20/2022 to 05/18/2022, indicated for a skilled nurse (SN) to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated for the SN to perform blood sugar and oxygen saturation every visit; report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of Patient 2’s Skilled Nurse Visit/Progress Notes for the certification period of 03/20/2022 to 05/18/2022, indicated that there was no documentation that patient’s O2 saturation was checked. Patient 2’s Skilled Nurse Visit/Progress Notes further indicated that on 03/22/2022 the blood sugar was not checked. Patient 2’s Skilled Nurse Visit/Progress Notes indicated that the random blood sugar on 03/24/2022 was 365 and on 04/07/22 it was 389, there was no documentation that the physician was notified regarding the blood sugar being outside the parameters. During an interview with the DPCS 05/09/2022 at 12:50 p.m., he stated that there was no documentation that Patient 2’s O2 saturation was checked during nursing visits. The DPCS further stated that Patient 2’s blood sugar should be checked every visit and if blood sugar is outside the parameters the nurse should notify the agency and the physician.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to have qualified personnel by failing to: 1. Ensure one of 28 staff (Licensed Vocational Nurse 9 [LVN 9]) had the required experience to work for the agency. 2. Ensure five of 28 staff (Registered Nurse (RN) RN5, RN6, LVN1, LVN3, LVN5) had updated History and Physical examinations. 3. Ensure three of 28 staff (RN1, RN5, and RN6) had updated Basic Life Support Certificates. 4. Ensure one of 28 staff (RN6) had a resume. 5. Ensure two of 28 staff ( RN6 and LVN9) had a completed work application. 5. Ensure six of 28 staff (RN5, RN6, RN7, LVN1, LVN3, and LVN5) had an updated Purified Protein Derivative (PPD) skin test (test that determines if you have tuberculosis [serious lung infection]). 6. Ensure six of 28 staff ( RN7, LVN2, LVN9, LVN12, RN Coordinator, and Quality Assurance Assistant) received a facility orientation. 7. Ensure one of 28 staff (LVN12) had an education/employment background check. 8. Ensure two of 28 staff (LVN9 and LVN12) had a competency review. These failures has the potential risk for these patients not to receive quality of care and services provided by the unqualified personnel, During an interview on 5/5/2022, at 12:30 p.m., LVN9 stated that she has been employed at HHA since October 2021. During a concurrent interview and record review on 5/10/2022 at 11:30 a.m. with the Assistant Clerk (AC), employee records were reviewed. AC stated that employees should have a History & Physical annually and a Purified Protein Derivative (PPD) skin test (test that determines if you have tuberculosis [serious lung infection]) every 2-3 years. AC reviewed and confirmed the following: -LVN 9’s work application was blank, was issued her nursing license on 5/4/2021, and her competency file was not completed. -RN 5, RN 6, LVN 1, LVN 3, and LVN 5 did not have their History and Physical in their personnel files. -RN 1, RN 5, and RN 6 had no updated Basic Life Support Certificate in their personnel files. -RN 6’s work application was blank and there was no Resume in her personnel file. -RN 5, RN 6, RN 7, LVN 1, LVN 3, and LVN 5 had no updated PPD in their personnel files. -RN 7, LVN 2, LVN 9, LVN 12, Intake Coordinator and Quality Assurance Assistant did not have evidence of being oriented to the agency when hired. -LVN 12 had no documentation that her education/employment background was verified. -LVN 9 and LVN 12 did not have competencies in their personnel files. During a concurrent interview and record review on 5/10/2022, at 12:30 p.m., with Administrator (ADM) of LVN 9’s employment application, LVN 9’s employment application had the date of the application, her name, her address, her social security number, and her signature. ADM stated that, “the first thing is their license, we check their license to practice nursing” when asked what their employment requirements were. ADM stated that LVNs required one year experience, which he asked LVN 9 when he conducted her interview. ADM stated that LVN 9’s license was issued on 5/4/21 and her employment application was filled out on 10/27/2021. ADM stated that LVN 9’s date of hire was 10/27/2021. ADM stated that LVN 9 had 5 months of nursing experience when she was hired. ADM stated, “I didn’t do it” when asked what it means if there is no documentation. During a concurrent interview and record review on 5/10/2022, at 1 p.m., with ADM, LVN 12 personnel file was reviewed. ADM stated he did not verify her education or employment background. ADM stated that he conducted LVN 12’s facility orientation and competency over the telephone. ADM stated that before employees go into the field orientation and a competency check should be completed. ADM stated that he had not done any competencies for a couple of years. During a concurrent interview and record review on 5/10/2022 at 1:30 p.m. with the Assistant Clerk (AC), LVN12 personnel file was reviewed. AC stated that LVN did not have documentation that she had orientation or prior employment or education background check. AC stated that LVN 12 did not have her History & Physical, PPD, or resume in her personnel file. A review of LVN 9’s “Job Description Summary” dated and signed by LVN9 on 10/27/2021 indicated as a position qualification an LVN is supposed to have three years nursing experience and shall have one-year prior professional nursing experience in Community/home health or medical/surgical experience for employment. A review of LVN 9’s “Board of Vocational Nursing and Psychiatric Technicians Licensing Details” dated 10/27/2021 indicated LVN was issued her license on May 4, 2021. A review of facility’s policy titled, “Job Description (Licensed/Practical Vocational Nurse)” revised March 2018 indicated one of the qualification is to have a minimum of one (1) year experience in nursing. A review of facility’s policy titled, “Administrator Job Description” Revised March 2018 indicated one of the ADM responsibilities include to employ qualified personnel and ensures adequate staff education and evaluations. A review of facility’s policy titled, “Personnel Records” revised March 2018 indicated the personnel record for an employee will include: -employment application, -observed competencies- initial and ongoing, -references or work history, -CPR is required, -verification of education, certification and/or license, -agency employee orientation. The policy also indicated that the health record for applicable employees will include: -PPD test or chest x-ray results, -at least two (2) reference checks prior to hire.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health agency (HHA) agency failed to ensure the Condition of Participation for Clinical Records was met as follows: 1. The HHA failed to ensure the Certified Home Health Aide (CHHA) documented and uploaded the current clinical notes for one of 10 sampled patients (Patient 9). Refer to G 1012 2. The HHA failed to discharge a patient and complete a discharge summary for one of 10 sampled patients (Patients 2). Refer to G 1022 3. The HHA failed to ensure that the Outcome and Assessment Information Set (OASIS) was reviewed, approved and signed for nine out of 10 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, and 9). Refer to G 1024 The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure the Certified Home Health Aide (CHHA) documented and uploaded the current clinical notes for one of 10 sampled patients (Patient 9). This failure had the potential for the recent patient care services and health assessments will not be coordinated to the other health care personnel. Findings: A review of Patient 9’s “Patient Demographic” indicated Patient 9 was admitted on 1/28/2022 with a diagnosis of Cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain) and Dysphagia (difficulty or discomfort in swallowing). A review of Patient 9’s “Home Health Certification and Plan of Care” (POC) dated 3/29/2022 – 5/27/2022 indicated Patient 9 had a Skilled Nursing (SN) visit for 1 time per week for 9 weeks and Certified Home Health Assistant (CHHA) visit 1 times per week for 9 weeks. During a review of Patient 9’s calendar for episode period 3/29/2022 to 5/27/2022 indicated Patient 9 had a CHHA visit on 4/20/2022 and 4/27/2022. During a concurrent interview and record review on 5/9/2022, at 11 a.m., with Administrator (ADM) of Patient 9’s electronic medical record, there were no CHHA notes on file for 4/20/2022, 4/27/2022, and 5/4/2022. ADM stated, “The CHHA has not submitted her notes. They have 3-5 days to submit. I will follow up with her.” A review of facility’s policy titled, “Home Health Aide Services and Documentation” revised March 2018 indicated “The Agency will ensure accurate documentation of home health aide services. The original documentation will be filed in the medical record within seven (7) days of the visit.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to discharge a patient and complete a discharge summary for one of 10 patients (Patients 2). This deficient practice resulted in staff being unaware that Patient 2 was discharged and Patient 2 continued to remain on the HHA’s current census. A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/19/2022, with diagnoses which included type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 2's Plan of Care (POC) for the certification period of 03/20/2022 to 05/18/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient two times a week for two weeks and then one time a week for seven weeks. The POC indicated that the SN is to perform blood sugar and oxygen saturation every visit and the SN report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of the agency’s Patient Census Report dated 05/04/2022, indicated Patient 2 was listed as a current active patient. During an interview with the DPCS on 05/04/2022 at 1:28 p.m., he stated that Patient 2 was transferred to hospice facility and that last nursing visit was on 04/21/2022. DPCS further stated that he was not aware that Patient 2 was transferred to hospice facility and that he just found out today. During an interview with the DPCS on 05/06/2022 at 3:43 p.m., he stated that Patient 2 did not have a discharge Outcome and Assessment Information Set (OASIS) (used to collect and report assessment data) or a discharge summary. The DPCS further stated that it was his responsibility to complete the discharge/transfer OASIS and it should be completed within 48 hours. A review of the agency’s policy and procedure titled, “Discharge Criteria and Process,” dated 10/2015, indicated that a discharge summary will be completed for all discharged patients. The policy and procedure further indicated that all discharge paperwork will be due in the office within 72 hours of the date of discharge.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on observation interview and record review, the facility failed to ensure nine out of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9) Outcome and Assessment Information Set (OASIS) were reviewed, approved and signed. This failure resulted in an incomplete submission of the OASIS information as required. e. During a review of Patient 5’s “Patient Demographic” indicated Patient 5 was admitted on 11/24/2021 with a diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and Cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right lower limb. During a review of Patient 5’s “Home Health Certification and Plan of Care” (POC) dated 11/24/2021 to 01/22/2022 indicated Patient 5 had Skilled Nursing (SN) visits ordered twice a week for one week then, three ties a week for eight weeks. Patient 5 also had Certified Home Health Aide (CHHA) visits for twice a week for nine weeks. During a record review on 5/5/2022 at 2:30 p.m. with Administrator (ADM) of Patient 5's electronic medical records, the medical record indicated Patient 5’s Start of Care OASIS had no signature and Resumption of Care OASIS dated 1/22/2022 and lock date of 1/27/2022 had no signature f. During a review of Patient 6’s “Patient Demographic” indicated Patient 6 was admitted on 11/2/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). During a review of Patient 6’s “Plan of Care” dated 3/2/2022 – 4/30/2022 indicated Patient 6 was oriented and forgetful. Patient 6 had Skilled Nursing visits ordered once a week for nine weeks. SN to perform at every visit: vital signs, blood sugar, weight, and document, and 02 saturation reading. During a record review on 5/5/2022 at 2:30 p.m. with ADM of Patient 6's electronic medical records, the medical record indicated Patient 6’s Start of Care OASIS dated 4/2/2022 and lock date of 11/5/2021 had no signature. Patient 6’s Recertification dated 2/27/2022 and lock date of 3/4/2022 had no signature. g. During a review of Patient 7’s “Patient Demographic” indicated Patient 7 was admitted on 4/2/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). During a review of Patient 7’s “Home Health Certification and Plan of Care” (POC) dated 4/2/2022 to 5/31/2022 indicated Patient 7 had Skilled Nursing (SN) visits ordered once a week for one week then, twice a week for two weeks then, once a week for six weeks. During a record review on 5/5/2022 at 2:30 p.m. with ADM of Patient 7's electronic medical records, the medical record indicated Patient 7’s Start of Care OASIS dated 4/2/2022 and a lock date of 4/8/2022 had no signature. h. During a review of Patient 8’s “Patient Demographic” indicated Patient 8 was admitted on 10/1/2021 with a diagnosis of Guillain-Barre Syndrome (a rare disorder in which your body's immune system attacks your nerves) and Pressure Ulcer of left buttocks, stage II (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Patient 8’s “Home Health Certification and Plan of Care” (POC) dated 3/30/2022 – 5/28/2022 indicated Patient 8 had Skilled Nursing (SN) visit for twice a week for 2 weeks then, once a week for seven weeks. The POC also indicated Patient 8 was alert, oriented, able to focus and shift attention, comprehensive and recalls task directions independently. During a record review on 5/5/2022 at 2:30 p.m. with ADM of Patient 8's electronic medical records, the medical record indicated Patient 8’s Recertification OASIS dated 3/27/2022 and a lock date of 4/1/2022 had no signature. i. During a review of Patient 9’s “Patient Demographic” indicated Patient 9 was admitted on 1/28/2022 with a diagnosis of Cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain) and Dysphagia (difficulty or discomfort in swallowing). During a review of Patient 9’s “Home Health Certification and Plan of Care” (POC) dated 3/29/2022 – 5/27/2022 indicated Patient 9 had Skilled Nursing (SN) visit for one time per week for nine weeks and Certified Home Health Assistant (CHHA) visit for one times per week for nine weeks. During a record review on 5/5/2022, at 2:30 p.m., with ADM of Patient 9's electronic medical records, the medical record indicated Patient 9’s Recertification OASIS dated 3/28/2022 and a lock date of 4/1/2022 had no signature. During an interview on 5/5/2022, at 2:35 p.m., with Administrator (ADM), the ADM stated that the Reporting of Outcome and Assessment Information Set (OASIS) was signed the next day after discussing the case. During an interview on 5/5/2022, at 2:38 p.m., with Administrator (ADM), the ADM stated that the Reporting of Outcome and Assessment Information Set (OASIS) needs to be turned in within 5 days. ADM stated that once he goes over the OASIS with the nurse he signs it, making sure everything is completed. ADM stated, “That’s an ongoing problem with our RN’s, either they forget it and they don’t go back and sign”. A review of facility’s policy titled, “Reporting of Outcome and Assessment Information Set (OASIS) Information” revised February 2021 indicated “The Agency will report electronically all OASIS data collected according to current federal and/or state requirements… Agency will electronically transmit completed, encoded and locked OASIS date for each completed OASIS assessment at least monthly to the System.” a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 02/10/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 02/10/2022 to 04/10/2022, indicated for the skilled nurse (SN) to visit patient two times a week for one weeks, then three times a week for two weeks, then two times a week for two weeks and then one time a week for four weeks. The SN was to perform blood sugar check and weigh Patient 1 every visit and document. SN was to perform a complete physical assessment each visit with emphasis on disease process. The SN was to report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of Patient 1’s OASIS with an assessment date of 02/10/2022, indicated it was not signed or dated. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 05/09/2022 at 3:05 p.m., he confirmed that Patient 1’s OASIS was not signed and dated. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/19/2022, with diagnoses which included type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 2's Plan of Care (POC) for the certification period of 03/20/2022 to 05/18/2022, indicated skilled nurse (SN) to visit the patient two times a week for two weeks and then one time a week for seven weeks. The SN was to perform blood sugar and oxygen saturation every visit and to report to the physician any significant change in clinical condition and random blood sugar greater than 350 milligrams per deciliter (mg/dl – unit if measurement). A review of Patient 2’s OASIS with an assessment date of 01/19/2022, indicated that it was not signed or dated. During an interview and concurrent record review with the DPCS on 05/09/2022 at 12:50 p.m., he confirmed that Patient 2’s OASIS was not signed and dated. c. A review of Patient 3's clinical record indicated a start of care date (SOC) of 04/18/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left and right heel, stage three (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and pressure ulcer to left and right buttocks, stage three. A review of Patient 3's Plan of Care (POC) for the certification period of 04/18/2022 to 06/16/2022, indicated skilled nurse (SN) to visit the patient two times a week for two weeks and then one time a week for seven weeks. The SN to perform a complete physical assessment each visit with emphasis on disease process. SN to assess the disease process of stage three pressure ulcer to the right heel, left heel, and right buttock. A review of Patient 3’s OASIS with an assessment date of 04/20/2022, indicated it was not signed or dated. During an interview and concurrent record review with the DPCS on 05/09/2022 at 12:22 p.m., he confirmed that Patient 3’s OASIS was not signed and dated. d. A review of Patient 4's clinical record indicated a start of care date (SOC) of 03/15/2022, with diagnoses which included pressure ulcer (areas of localized damage to the skin and underlying tissue) to the left buttock, stage three (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 4's Plan of Care (POC) for the certification period of 03/15/2022 to 05/13/2022, indicated skilled nurse (SN) to visit the patient for wound care every other day until 03/26/2022, then three times a week for 2 weeks and then two times a week for five weeks starting week of 03/27/2022. A review of Patient 4’s OASIS with an assessment date of 03/15/2022, indicated that it was not signed or dated. During an interview and concurrent record review with the DPCS on 05/09/2022 at 11:55 a.m., he confirmed that Patient 4’s OASIS was not signed and dated.