Every finding on record at Palm Valley Health Care Inc

Purpose of Visit - To conduct a Recertification Survey. Entrance Date - 03/30/21 Census: 2 Licensed and Certified - 2 Palm Valley Health Care Inc. was not in compliance with the following Conditions of Participation: COP: 484.102 Establishment of the Emergency Program. Partial Extended Survey An exit conference was conducted on 04/01/2021 at 12:01 p.m. with the Adm/DON, the AA/Owner and the ADON. The preliminary findings were discussed with agency staff. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Administrator/Director of Nursing - Adm/DON Alternate Administrator/Owner - AA/Owner Alternate DIrector of Nursing - ADON Human Resources - HR Licensed Vocationa Nurse/Quality Assurance and Performance Improvement/Quality Assurance - LVN/QAPI/QA Registered Nurse - RN Licensed Vocational Nurse - LVN Licensed Vocational Nurse/Quality Assurance - LVN/QA

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: E-0004; Development of Emergency Plan, Review and Update Annually Based on record review and interviews, the agency failed to review its written emergency preparedness and response plan at least once a year and after an actual emergency response to decide if the plan worked and to update it if needed for 2020 and currently in 2021. E-0007; Emergency Program and Patient Population Based on record review and interview, the Agency's written emergency preparedness and response plan failed to include a continuity of operation business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. E-0017; Hha Comprehensive Assessment in Disaster Based on record reviews and interviews, the agency failed to include or use in its emergency preparedness and response plan, procedures to triage patients that allows the agency to categorize patients into groups based on services provided; the need for the services; their ability to evacuate and the patients medical and psychiatric condition and home environment. E-0029; Development of Communication Plan Based on record review and interview, the agency's Emergency Preparedness and Response Plan failed to include a communication plan that complied with 42 Code of Federal Regulation (CFR) 484.22(c), for 2019, 2020 and currently in 2021. E-0033; Methods for Sharing Information Based on record review and interview, the Agency's written emergency preparedness and response plan failed to include procedures to release patient information in the event of a disaster for 2020 and currently in 2021.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to review its written emergency preparedness and response plan at least once a year and after an actual emergency response to decide if the plan worked and to update it if needed for 2020 and currently in 2021. This failure placed the agency's 2 active patients at risk for harm by staff not being prepared to respond in an actual man-made or natural disaster. The Findings Included: At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QALVN) the Surveyor requested the Agency's Emergency Preparedness Manuels for 2019, 2020 and 2021, and an Employee list with titles and hire dates. On 03/30/21 at approximately 11:00 a.m. the Adm/DON brought the surveyor the employee list with titles and hire dates. In an interview conducted on 03/30/21 at 11:50 a.m. with the Adm/DON the Surveyor again requested the Agency's Emergency Preparedness Manuels for 2019, 2020, and 2021. In an interview conducted on 03/30/21 at 12:30 p.m. with the Adm/DON, the Surveyor requested, for the third time, the Agency's Emergency Preparedness Manuel 2019, 2020 and 2021. Review of the Agency's Policy and Proceedure Manual revealed a policy titled "Emergency Preparedness", it was numbered 19, but had no date. It read in part: "The Agency will develop and implement an emergency preparedness and response plan that comprehensively describes the Agency's approach to a disaster..." Continued review of the Emergency Preparedness policy read in part: "The Emergency Preparedness and Response Plan will be reviewed annually and after each actual emergency." At 01:31 p.m. the ADON brought the Surveyor an Emergency Preparedness Manual, one binder, the ADON stated "I know that it's not done like it is supposed to be." Review of the Agency's Emergency Preparedness manual included an agency form titled "Emergency Preparedness and Response Plan." It had a revision date of 03/19. Note The Agency's owner has another company under another license with the same name just desiginated by a number i.e. Agency #1 and Agency #2. Agency #1 is Personal Assistant Services only, Agency #2 has Licensed and Certified, Licensed Home Health and Personal Assistant Services. Agency #2 is the license that is being surveyed. The Emergency Preparedness Plan was 15 pages long. On page 15 was an Agency form titled "Agency Name Personal Assistance Service Telephone Tree." There was no other telephone tree in the plan. There were no Registered Nurses listed on the tree, and the employee list did not match the employee list with titles that the Surveyor requested and received. Based on record review and interviews, the agency failed to review its written emergency preparedness and response plan at least once a year and after an actual emergency response to decide if the plan worked and to update it if needed for 2020 and currently in 2021. This failure placed the agency's 2 active patients at risk for harm by staff not being prepared to respond in an actual man-made or natural disaster. The Findings Included: At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QALVN) the Surveyor requested the Agency's Emergency Preparedness Manuels for 2019, 2020 and 2021, and an Employee list with titles and hire dates. On 03/30/21 at approximately 11:00 a.m. the Adm/DON brought the surveyor the employee list with titles and hire dates. In an interview conducted on 03/30/21 at 11:50 a.m. with the Adm/DON the Surveyor again requested the Agency's Emergency Preparedness Manuels for 2019, 2020, and 2021. In an interview conducted on 03/30/21 at 12:30 p.m. with the Adm/DON, the Surveyor requested, for the third time, the Agency's Emergency Preparedness Manuel 2019, 2020 and 2021. At 01:31 p.m. the ADON brought the Surveyor an Emergency Preparedness Manual, one binder, the ADON stated "I know that it's not done like it is supposed to be." Review of the Agency's Emergency Preparedness manual included an agency form titled "Emergency Preparedness and Response Plan." It had a revision date of 03/19. Note The Agency's owner has another company under another license with the same name just desiginated by a number i.e. Agency #1 and Agency #2. Agency #1 is Personal Assistant Services only, Agency #2 has Licensed and Certified, Licensed Home Health and Personal Assistant Services. Agency #2 is the license that is being surveyed. The Emergency Preparedness Plan was 15 pages long. On page 15 was an Agency form titled "Agency Name Personal Assistance Service Telephone Tree." There was no other telephone tree in the plan. There were no Registered Nurses listed on the tree, and the employee list did not match the employee list with titles that the Surveyor requested and received. Continued review of the Agency's Emergency Preparedness Manual failed to contain documentation of an emergency preparedness and response plan that comprehensively describes the Agency's approach to a disaster for 2020 and currently in 2021. Further review of the Agency's Emergency Preparedness Manual failed to contain an annual or bi-annual review of the Emergency Preparedness plan to evaluate its effectiveness for 2020 and currently in 2021. During an interview on 03/31/21 at 08:45 a.m. with the Alternate Director of Nusing (ADON), the surveyor presented the above findings. After review of the Emergency Preparedness Plan, the ADON stated "Okay, I know we don't have it for 2020 and 2021." Review of the Agency's Policy and Proceedure Manual revealed a policy titled "Emergency Preparedness", it was numbered 19, but had no date. It read in part: "The Agency will develop and implement an emergency preparedness and response plan that comprehensively describes the Agency's approach to a disaster..." Continued review of the Emergency Preparedness policy read in part: "The Emergency Preparedness and Response Plan will be reviewed annually and after each actual emergency."

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the Agency's written emergency preparedness and response plan failed to include a continuity of operation business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. This failure could place the Agency's 2 active Licensed and Certified patients at risk of harm from the possibility of the agency being unable to function following a disaster. The Findings Included: Review of the Agency's Emergency Preparedness manual included an agency form titled "Emergency Preparedness and Response Plan" it was dated 03/19. Continued review of the Emergency Preparedness and Response Plan revealed a "Continuation of Business Plan" on page 4. It read in part: "The Agency's goal of the Continuation of Operations Business plan is to safely provide clients with continued authorized services as long as possible and with minimal disruption of schedule." Review of the agency's Emergency Preparedness Manual failed to reveal documentation of a continuity of operations business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. During an interview on 03/31/21 at 08:45 a.m. with the ADON, the Surveyor asked if the agency's Emergency Preparedness Plan included a Continuity of Operations Business Plan that addressed emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. After review of the Emergency Preparedness Manual and the Emergency Preparedness Plan, the ADON stated "Okay, I understand that it's not complete." Review of the Agency's Policy and Procedure manual revealed a policy titled "Emergency Preparedness" it was numbered 19. but was not dated. It read in part: "The continuation of Operations Plan will include: emergency financial needs, essential functions for client services, critical personnel and how to return to normal operations as quickly as possible."

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: [(b) Policies and procedures. The HHA 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.] At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. Based on record reviews and interviews, the agency failed to include or use in its emergency preparedness and response plan, procedures to triage patients that allows the agency to categorize patients into groups based on services provided; the need for the services; their ability to evacuate and the patients medical and psychiatric condition and home environment. This failure could place the Agency's 2 active Licensed and Certified patients at risk of harm from emergency management personnel not having adequate information on the triage categories to assign to agency patients. The Findings Included: Review of the Agency's Emergency Preparedness and Response Plan failed to include a current list of patients whose triage category had been assessed and incorporated into the emergency preparedness plan for 2019, 2020 and currently in 2021, in that the Patient list had been omitted from the plan for 2019, 2020 and 2021. During an interview on 03/31/21 qt 08:45 a.m. with the Alternate Director of Nursing (ADON), the Surveyor asked if the agency's Emergency Preparedness and Response Plan included a current list of patients whose triage category had been assessed and incorporated into the emergency preparedness plan. After review of the Emergency Preparedness Manual, and the Emergency Preparedness Plan for 2019, 2020 and currently in 2021, the ADON stated "No." Review of the Agency's Policy and Procedure manual revealed a Policy titled "Emergency Preparedness." It was numbered 19 but was not dated. It read in part: "(12) The triage system will allow for quick access to recorded information about an active patients triage category in the event of an emergency..." Continued review of the Emergency Preparedness." policy read in part: "(9) Patients will be triaged in accordance with the following: a) Services Provided by the Agency b) Patients need for continuity of the services provided by the agency and c) Availability of someone to assume responsibility for the Patients emergency response plan if needed by the patients." Further review of the policy titled "Emergency Preparedness" policy read in part: " The Agency must complete an internal review of the plan at least annually..." The agency did not provide any additional information by the time of the exit at 04/01/21 at 12:01 p.m.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's Emergency Preparedness and Response Plan failed to include a communication plan that complied with 42 Code of Federal Regulation (CFR) 484.22(c), for 2019, 2020 and currently in 2021. This failure could place the agency's 2 active Licensed and Certified patients and any future clients at risk for harm from the possibility of the agency being uninformed and unprepared for a disaster or emergency. The Findings Included: According to the Code of Federal Regulations (CFR) § 484.22 (c) "Communication plan. The HHA must develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all the following: (1) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually] The communication plan must include all the following: Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other [facilities]. (v) Volunteers. (2) Contact information for the following: (i) Federal, State, tribal, regional, or local emergency preparedness staff. (ii) Other sources of assistance. (3) Primary and alternate means for communicating with the HHA's staff, Federal, State, tribal, regional, and local emergency management agencies. (4) A method for sharing information and medical documentation for patients under the HHA's care, as necessary, with other health care providers to maintain the continuity of care. (5) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). (6) A means of providing information about the HHA's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee." Continued review of the Agency's Emergency Preparedness Manual failed to reveal documentation that the Agency's Emergency Preparedness Plan included a Communication Plan that complied with 42 Code of Federal Regulation (CFR) 484.22(c) for 2019, 2020 and 2021. During an interview on 03/31/21 at 08:45 a.m. with the Alternate Director of Nursing (ADON), the Surveyor presented the above findings and asked if there was documentation of the Communication Plan that the Agency had developed for the Emergency Preparedness Plan for 2019, 2020 and currently in 2021 that complied with 42 Code of Federal Regulation (CFR) 484.22(c). The ADON stated: "No." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Emergency Preparedness", it was numbered 19 and was not dated. It read in part: ""d. The Agency's written Emergency Preparedness and response plan must describe the following: 4. Procedures for communicating with staff, clients or persons resopnsible for a clients emergency response plan; local, state and federal emergency management agencies; and other entities including the Health and Human Services Commision and other healthcare providers and suppliers..." Continued review of the Emergency Preparedness policy read in part: "The Emergency Preparedness and Response Plan will be reviewed annually and after each actual emergency."

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on record review and interview, the Agency's written emergency preparedness and response plan failed to include procedures to release patient information in the event of a disaster for 2020 and currently in 2021. This failure could place the agency's 2 active Licensed and Certified patients at risk of harm in the event of an emergency when the agency is not able to release information to assist the authorities in knowing which patients may need evacuation and other services in an emergency. The Findings Include: Review of the Agency's Emergency Preparedness Manual included an agency form titled "Emergency Preparedness and Response Plan." It had a revision date of 03/19 and it included Agency Drills and Drill Performance Evaluations from 2019, 2020 and 2021. Continued review of the Emergency Preparedness and Response plan read in part: "4. Privacy and Disclosure of Private Health Information (a) in accordance with the Agency's Policy the Agency will only disclose information to assist the patient in an emergency situation and will discolse only the minimum necessary to assist the patient..." Further review of the Emergency Prepardness and Response plan failed to contain documentation of a method for sharing information and medical documentation for patients under the Agency's care, as necessary, with the patients and other health providers to maintain the continuity of care, or as a means of providing information about the general condition and location of patients under the Agency's care. During an interview on 03/31/21 at 08:45 a.m. with the Alternate Director of Nursing (ADON), the Surveyor presented the above findings and asked if the agency had a written emergency preparedness and response plan that included procedures to release client information in the event of a disaster for 2020 and currently in 2021. The ADON stated, "No." Review of the agency's Policies and Procedures Manual revealed a policy form titled "Emergency Preparedness" it was numbered 19, but was not dated. It read in part: "3. The plan will include the following: include procedures to release patient information in the even of a disaster."

Palm Valley Health Care Inc. Initial Comments Purpose of Visit - To conduct a Recertification Survey. Entrance Date/Time - 03/30/21 at 10:27 a.m. Census: 2 Licensed and Certified: 2 Palm Valley Health Care Inc. was not in compliance with the following Conditions of Participation: COP: 484.50 Patient Rights COP: 484.60 Care Planning, Coordination of Services and Quality of Care. COP: 484.65 Quality Assessment and Performance Improvement COP: 484.105 Organization and Administration of Services. Partial Extended Survey An exit conference was conducted on 04/01/2021 at 12:01 p.m. with the Adm/DON, the AA/Owner and the ADON. The preliminary findings were discussed with agency staff. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Administrator/Director of Nursing - Adm/DON Alternate Administrator/Owner - AA/Owner Alternate Director of Nursing - ADON Human Resources - HR Licensed Vocational Nurse/Quality Assurance and Performance Improvement/Quality Assurance - LVN/QAPI/QA Registered Nurse - RN Licensed Vocational Nurse - LVN Licensed Vocational Nurse/Quality Assurance - LVN/QA SN - Skilled Nurse

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. G-434; Participate in Care Based on clinical record review and interview, the Agency failed to respect the patient's rights to have an established individualized Plan of Care (POC [ 485] ) for 1 of 2 (#1) active Agency Licensed and Certified patients and 1 of 5 (#6) discharged Licensed and Certified patient whose clinical records were reviewed in that the certification period was completed without a Physician signed Plan of Care.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the Agency failed to respect the patient's rights to have an established individualized Plan of Care (POC [ 485] ) for 1 of 2 (#1) active Agency Licensed and Certified patients and 1 of 5 (#6) discharged Licensed and Certified patients whose clinical records were reviewed. In that the certification period was completed without a Physician signed Plan of Care. This failure violates patients right to have their physical needs treated and hinders a detailed approach to care customized to an individual patients needs and consented to by the patients attending physician. The Findings included: Review of Active Patient #1's electronic clinical record for the completed Certification Period of 01/29/21 thru 03/29/21, showed diagnoses of Transient Ischemic Attacks (TIA's or mini strokes) and A Pressure Ulcer Stage 2. Review of the POC included a skilled nurse (SN) visit frequency of one time per day for 60 days. It also included Wound Care orders, many Teachings, Treatments and New Medications. Continued review of the POC revealed that the Attending Physician had not signed the POC for the certification period of 01/29/21 thru 03/29/21. During and interview conducted on 03/31/21 at 09:24 a.m. with LVN/QA G, the surveyor presented the above finding and asked her to check if they had the signed POC for Patient #1's Certification Period of 01/29/21 thru 03/29/21. LVN/QA G checked her records and stated "No, we don't have it." On 03/31/21 at 11:17 a.m. the AA/Owner brought the Surveyor a signed Physician copy of Patient #1's POC for Certification Period of 01/29/21 thru 03/29/21. The AA/Owner stated "They told me you were looking for this, okay now? The Surveyor explained that the Agency nurses provided care for the entire certification period without a physician's order to do so. The Physician dated the POC 03/31/21, after the certification period had ended. Review of Discharged Patient #6's electronic clinical record for the completed Certification Period of 08/04/20 thru 10/02/20, showed diagnoses of High Blood Pressure and Atrial Fibriliation (irregular heart beat). Review of the POC included a skilled nurse (SN) visit frequency of one time per week for one week, then 2 times per week for one week and then one time per week for seven weeks. It also included Physicial Threrapy orders, many teachings, treatments and New Medications. Continued review of the POC revealed that the Attending Physician had not signed the POC for the certification period of 08/04/20 thru 10/02/20. Also reviewed for Discharge Patient #6 was the completed Certification Period of 06/05/20 thru 08/03/20, it showed diagnoses of High Blood Pressure and Hyperlipidemia (a high concentration of fat in the blood). Review of the POC included a SN visit frequency of one time per week for one week, then 2 times per week for one week and then one time per week for seven weeks. Continued review of the POC revealed that the Attending Physician had not signed the POC for the certification period of 06/05/20 thru 08/03/20. Discharged Patient #6 went through two complete certification periods without a Attending Physician signed POC. During an interview on 04/01/21 at 09:24 a.m with LVN/QA G, the surveyor presented the above findings and asked her to check to see if they had signed Plans of Care for discharged Patient #6 for the completed Certification Periods of 08/04/20 thru 10/02/20 and 06/05/20 thru 08/03/20. LVN/QA G checked her records and stated "No we don't have them, I am checking with the doctor now." During an interview and concurrent record review conducted on 04/01/21 at 11:36 a.m with the Administrator/Director of Nursing, the Alternate Director of Nursing and the Alternate Administrator/Owner the Surveyor presented the above findings and asked if the Plans of Care for Patient #1 and Patient #6 had been signed by the Physician. After review of the 3 Plans of Care respectively, the Adm/DON stated "Ah, no they weren't signed." They agreed that Patient #1 and Patient #6 did not get the chance to participate in their care when it came to establishing and revising their individual Plans Of Care. Review of the Agency's Policy and Procedure manual revealed a policy titled "Patient Rights and Responsibilities." It was not numbered but had a revision date of 02/2016. It read in part: "The patient has the right to be informed in advance about the care to be furnished and of any changes in the care to be furnished." Continued review of the Patient Rights and Responsibilities policy read in part: "The patient has the right to participate in the planning of the care or treatment and in planning changes in the care or treatment." Continued review of the Agency's policy and procedure Manual revealed a policy titled "Plan of Care/Care Plan", it was numbered 7, but was not dated. It read in part: "Skilled care follows a written Plan of Care (485) established and reviewed by a Doctor of Medicine..." Continued review of the Plan of Care/Care Plan policy read in part: "5. The Plan of Care will be developed following the assessment and hand carried, uploaded or mailed to Physician for signature. The written POC must be signed by the physician and returned to the agency." Further review of the Plan of Care/Care Plan policy read in part: "7. Care follows the written physician plan of care." Still further review of the Plan of Care/Care Plan policy read in part: "8. A Registered Nurse prepares the POC and submits to the Physician for signature." Continued review of the Plan of Care/Care Plan policy read in part: "10. The POC shall be reviewed and revised by the Attending Physician." Further review of the Plan of Care/Care Plan policy read in part: "11. The Patient will be informed of any changes in the POC before the changes are made." Further Review of the Agency's Policy and Procedure Manual revealed a policy titled "Acceptance of Physician Verbal Orders", it was numbered 8, but was not dated. It read in part: "The Physician must order all treatments and care furnished in the licensure category of licensed and certified home health services and licensed home health services."

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: G-572; Plan of Care Based on clinical record review and interview, the Supervising Nurse failed to ensure the patients plan of care was executed as written for 5 of 7 ( #1, #2, #3, #4 and #7) patients whose records were reviewed. 1. Licensed Vocational Nurses (LVN) C did not complete the required Skilled Nurse Visits (SN) for Patient #1 and as ordered on the Plan of Care (POC). 2. Registered Nurse (RN) B, RN C and Licensed Vocational Nurses (LVN) D, and E did not instruct Patient #2 and/or caregiver as ordered on the POC. 3. LVN F did not instruct Patient #3 and/or caregiver as ordered on the POC. 4. RN B, RN D, LVN E and LVN H did not instruct Patient #4 and/or caregiver as ordered on the POC. 5. LVN I checked Patient #7's Pulse Oxygenation Level without an order. G-600; Coordination of Care Based on record review and interview, the agency failed to enforce its written policy to ensure the effective exchange of information and coordination of patient services among all agency personnel providing care and services for 2 of 7 Patients (#1 and #2) whose records were reviewed.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and interview, the Supervising Nurse failed to ensure the patients plan of care was executed as written for 5 of 7 ( #1, #2, #3, #4 and #7) patients whose records were reviewed. 1. Licensed Vocational Nurses (LVN) C did not complete the required Skilled Nurse Visits (SN) for Patient #1 and as ordered on the Plan of Care (POC). 2. Registered Nurse (RN) B, RN C and Licensed Vocational Nurses (LVN) D, and E did not instruct Patient #2 and/or caregiver as ordered on the POC. 3. LVN F did not instruct Patient #3 and/or caregiver as ordered on the POC. 4. RN B, RN D, LVN E and LVN H did not instruct Patient #4 and/or caregiver as ordered on the POC. 5. LVN I checked Patient #7's Pulse Oxygenation Level without an order. Failure of the agency's skilled nurses to follow the plan of care placed the agency's 2 active Licensed and Certified patients and any future patients at risk of receiving inadequate care and services and could have placed the patients at risk of negative outcomes. The Findings Included: Review of the Administrator/Director of Nursing's (Adm/DON) personnel record, revealed a Job description that was dated 01/15/18 and signed by the Adm/DON. It read in part: "3. Assure the development imeplemtation and updates of the indidvidualized plans of care." 1. Review of active Patient #1's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 01/29/21 thru 03/29/21 with diagnoses of Transient Ischemic Attacks (mini strokes) and Pressure Ulcer Stage 2. The POC included a skilled nurse (SN) visit frequency of twice a week for every day times 60 days. Continued review of the POC revealed that it was not signed by the physician. Further review of Patient #1's electronic clinical record failed to reveal any documentation for SN visits dated 03/06/21, 03/07/21, 03/27/21 and 03/28/21. They were left blank. The four SN visits that were left blank, 03/06/21, 03/07/21, 03/27/21 and 03/28/21 were signed by LVN C. Still further review of Patient #1's electronic clinical record failed to reveal any documentation of coordination of care with the Agency Staff or Patient #1's Physician as to why the SN visits were omitted. In an interview and concurrent record review conducted on 04/01/21 at 11:36 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the four blank SN visit notes to the Adm/DON and asked if there was any completed documentation for those four SN visits. The Adm/DON Stated "No, there isn't. The Surveyor asked if there was any documentation of Coordination of Care with the Agency or Patient #1's Physician. After review the Adm/DON stated "No, there isn't." 2. Review of active Patient #2's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 12/16/21 thru 02/13/21 with diagnoses of Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The POC included a skilled nurse (SN) visit frequency of twice a week for one week and one time per week for eight weeks. The POC included an order for the Skilled Nurse (SN) to assess the integumentary status at ever visit. Review of the SN visit note dated 01/04/21 and signed by LVN E noted that Patient #2 had developed a rash. Review of Patient # 2's clinical record faild to include documentation that coordination of care, concerning the rash, was done with the Agency and Patient #2's attending physician. The POC included orders for the Skilled Nurse (SN) to perform a total of 8 skilled nursing visits and orders for teaching/instruction of Pain Control and Prevention, Nebulizer Cleaning, High Blood Pressure, Signs and Symptoms of Infection and the Specific Medications Albuterol and Metoprolol. Continued review of the POC revealed that it was signed by the physician on 01/29/21. The SN visit signed by RN B was dated 01/11/21. The SN visit signed by RN C was dated 02/22/21, The SN visits signed by LVN D were dated 12/21/20, 12/28/20, 01/20/21 and 01/25/21. The SN visits signed by LVN E were dated 01/04/21 and 02/05/21. All 8 of the SN Visit Notes failed to contain documentation that Patient #2 and/or the Caregiver were instructed on Pain Control and Prevention, Nebulizer Cleaning, High Blood Pressure, Signs and Symptoms of Infection and the Specific Medications Albuterol and Metoprolol. In an interview and concurrent record review conducted on 04/01/21 at 11:44 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings the teachings were pointed out, the Surveyor asked the Adm/DON if Patient #2 and/or the Caregiver thad been taught the following: Pain Control and Prevention, Nebulizer Cleaning, High Blood Pressure, Signs and Symptoms of Infection and the Specific Medications Albuterol and Metoprolol. After review the Adm/DON stated "No, I see." The Surveyor pointed out the SN visit note dated 01/04/21 and asked if there was any coordination of care documentation concerning the rash with the Agency and Patient #2's physician. The Adm/DON stated "Oh, I see, there isen't." 3. Review of discharged Patient #3's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 10/10/20 thru 12/08/20 with diagnoses of Type 2 Diabetes Mellitus and Chronic Pressure Ulcer. The POC included a skilled nurse (SN) visit frequency of three times a week for eight weeks, and a frequency change during the certification period on 10/28/20 of one time per week for 6 weeks, for a total of 14 SN visits. The POC included orders for the Skilled Nurse (SN) to perform a total of 14 skilled nursing visits and orders for teaching/instruction on the Disease Process for Type 2 Diabetes and Chronic Pressure Ulcer, Falls and Safety and Infection Control. Continued review of the POC revealed that it was signed by the physician. The SN visits signed by LVN F were dated 10/11/20, 10/13/20, 10/14/20, 10/16/20, 10/19/20, 10/21/20, 10/23/20, 10/26/20, 10/28/20, 11/04/20, 11/11/20, 11/18/20, 11/25/20 and 12/01/20. All 14 for the SN Visit Notes failed to contain documentation that LVN F instructed Patient #3 and/or the caregiver on the Disease Process for Type 2 Diabetes and Chronic Pressure Ulcer, Falls and Safety and Infection Control. In an interview and concurrent record review conducted on 04/01/21 at 11:46 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings the teachings were pointed out, the Surveyor asked the Adm/DON if Patient #3 and/or the Caregiver thad been taught the following: the Disease Process for Type 2 Diabetes and Chronic Pressure Ulcer, Falls and Safety and Infection Control. After review the Adm/DON stated "Okay, No, I understand." 4. Review of discharged Patient #4's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 02/10/20 thru 04/07/20 with diagnoses of Type 2 Diabetes Mellitus and Chronic Pressure Ulcer. The POC included a skilled nurse (SN) visit frequency one time per week for nine weeks. Review of Patient #4's clinical record revealed documentation that Patient #4 was prone to Urinary Tract Infections. The POC included orders for the Skilled Nurse (SN) to perform a total of 9 skilled nursing visits and orders for teaching/instruction on Genitourinary Status, Prevention of Urinary Tract Infections and Infection Control. Continued review of the POC revealed that it was signed by the physician on 03/06/20. The SN visit signed by RN B was dated 02/06/20. The SN visit signed by RN D was dated 04/10/20. The SN visits signed by LVN E were dated 02/20/20 and 03/26/20. The SN visits signed by LVN H were dated 02/15/20, 03/10/20, 03/15/20, 03/18/20 and 04/02/20. All 9 of the SN Visit Notes failed to contain documentation that Patient #4 and/or the caregiver was instructed on the Genitourinary Status, Prevention of Urinary Tract Infections and Infection Control. In an interview and concurrent record review conducted on 04/01/21 at 11:51 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings the teachings were pointed out, the Surveyor asked the Adm/DON if Patient #4 and/or the Caregiver thad been taught the following: Genitourinary Status, Prevention of Urinary Tract Infections and Infection Control. After review the Adm/DON stated "No, okay, I understand." 5. Review of discharged Patient #7's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 03/05/20 thru 05/03/20 with diagnoses of Type 2 Diabetes Mellitus with foot ulcer and Cellulitis of left lower limb. The POC included a skilled nurse (SN) visit frequency of one time per day for 60 days. Patient #7 was discharged on 03/17/20. The total Skilled Nurse visits for this certification period were 11. Review of the POC revealed that it was signed by the physician on 04/08/20. The POC did not include orders for the SN to assess Pulse Oximetry. (A noninvasive and painless test that measures oxygen levels in blood). The SN visit signed by LVN I were dated 03/06/20, 03/07/20, 03/08/20, 03/09/20, 03/10/20, 03/11/20, 03/12/20, 03/13/20, 03/14/20, 03/15/20 and 03/16/20. Ten of the eleven skilled nurse visits signed by LVN I, 03/06/20, 03/07/20, 03/09/20, 03/10/20, 03/11/20, 03/12/20, 03/13/20, 03/14/20, 03/15/20 and 03/16/20, included an assessment of Pulse Oximetry. 03/08/20 was a missed visit and documentation of the Missed Visit was completed by LVN I. In an interview and concurrent record review conducted on 04/01/21 at 11:56 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings and pointed out that there was no order on the POC for Pulse Oximetry for Patient #7, after Review the Adm/DON stated "There isn't, okay no order." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Plan of Care/Care Plan", it was numbered 7, but was not dated. It read in part: "Skilled care follows a written plan of care (485) established and periodically reviewed by a doctor..." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Clinical Record" it was numbered 19 but was not dated. It read in part: "The Agency will maintain a client record system to assure that the care and services provided to each client is completely and accurately documented, readily available and systematically organized to facilitate the compilation and retrieval of information."

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Standard: Coordination of care. The HHA must: Based on record review and interview, the agency failed to enforce its written policy to ensure the integration of patient services among all agency personnel providing care and services for 2 of 7 Patients (#1 and #2) whose records were reviewed. This failure could place the agency's 2 active Licensed and Certified patients at risk of inaccurate care and services and could result in negative health outcomes. The findings included: 1. Review of active Patient #1's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 01/29/21 thru 03/29/21 with diagnoses of Transient Ischemic Attacks (mini strokes) and Pressure Ulcer Stage 2. The POC included a skilled nurse (SN) visit frequency of twice a week for every day times 60 days. Continued review of the POC revealed that it was not signed by the physician. Further review of Patient #1's electronic clinical record failed to reveal any documentation for SN visits dated 03/06/21, 03/07/21, 03/27/21 and 03/28/21. They were left blank. The four SN visits that were left blank, 03/06/21, 03/07/21, 03/27/21 and 03/28/21 were signed by LVN C. Still further review of Patient #1's electronic clinical record failed to reveal any documentation of coordination of care with the Agency Staff or Client #1's Physician as to why the SN visits were omitted. In an interview and concurrent record review conducted on 04/01/21 at 11:36 a.m. with the Adm/DON, the ADON and the AA/Owner the Surveyor presented the four blank SN visit notes to the Adm/DON and asked if there was any completed documentation for those four SN visits. The Adm/DON Stated "No, there isn't. The Surveyor asked if there was any documentation of Coordination of Care with the Agency or Patient #1's Physician. After reviewing the Adm/DON stated "No, there isn't." 2. Review of active Patient #2's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 12/16/21 thru 02/13/21 with diagnoses of Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The POC included a skilled nurse (SN) visit frequency of twice a week for one week and one time per week for eight weeks. The POC included an order for the Skilled Nurse (SN) to assess the integumentary status at ever visit. Review of the SN visit note dated 01/04/21 and signed by LVN E noted that Patient #2 had developed a rash. Review of Patient # 2's clinical record failed to include documentation that coordination of care, concerning the rash, was done with the Agency and Patient #2's attending physician. Continued review of the POC revealed that it was signed by the physician on 01/29/21. In an interview and concurrent record review conducted on 04/01/21 at 11:44 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings. The Surveyor pointed out the SN visit note dated 01/04/21 and asked if there was any completed coordination of care documentation concerning the rash with the Agency and/or Patient #2's physician. The Adm/DON stated "Oh, I see, there isn't." Review of the Agency Policy and Procedure Manual revealed a policy titled "Coordination of Patient care with other health care providers and Agency Staff ", it was numbered 11, but was not dated. It read in part: "Quality coordination of care is provided and communicated to all patients, representatives and caregivers to ensure the patients' needs are met through an effective interchange and reporting with other health care providers providing services to patients and with the Agency's Staff. Coordination of care with Agency Staff will be accomplished through case conferences and other methods of communication..." Continued review of the Coordination of Patient care with other health care providers and Agency Staff policy read in part: "Documentation of Coordination of Care will be signed and dated and filed in the patients record." Continued review of the Agency's Policy and Procedure Manual revealed a policy titled "Communication with the Physician" it was numbered 12 but was not dated. It read in part: "All communication to or from physicians regarding a patient's condition and treatment will be documented in the patient's clinical record. Documentation must include who was spoken to, what information was reported, response, and any orders received and follow-up." Continued review of the Communication with the Physician policy read in part: "Information relevant to the patient's condition and treatment will be reported to the physician documented and physician orders generated when applicable may include but not limited to: C) Findings outside established parameters, E) Significant signs and symptoms associated with the patients' medical diagnoses or with yet undetected or unconfirmed diagnoses and I) Omission of services, treatments or diagnostic studies ordered."

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: G-642; Program Scope Based on record review and interview, the agency failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal patient care outcomes for 2019, 2020 and currently in 2021. G-658; Performance Improvement Project Based on record review and interview, the agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed and immediately corrected identified problems that directly or could potentially threaten the patient care and safety, in that the Agency did not have or complete a Performance improvement Project for 2019, 2020 and 2021. G-0660; Executive Responsibility for QAPI Based on record review and interview, the agency's Governing Body failed to ensure that the Quality Assessment Performance Improvement (QAPI) Committee met at least twice a year in 2020 and currently in 2021 to make sure that an ongoing program for quality improvement and patient safety was defined implemented and maintained.

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 record review and interview, the agency failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal patient care outcomes for 2019, 2020 and currently in 2021. This failure could place the agency's active Licensed and Certified patients at risk of receiving inadequate care and services due to the agency not being able to trend patterns in issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff, client complaints, the agency's response to complaints, competency of care and client incidents and occurrences and/or the agency response to incidents and occurrences. The Findings Included: At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QA/LVN) the Surveyor requested the Agency's QAPI Manuals for 2019, 2020 and 2021. In an interview conducted on 03/30/21 at 11:50 a.m. with the Adm/DON the Surveyor again requested the Agency's QAPI Manual's for 2019, 2020, and 2021. In an interview conducted on 03/30/21 at 12:30 p.m. with the Adm/DON, the Surveyor requested, for the third time, the Agency's QAPI Manual's for 2019, 2020 and 2021. In an interview conducted on 03/30/21 at 01:10 p.m. with the Adm/DON the Surveyor requested, for the fourth and last time, the Agency's QAPI Manual's for 2019, 2020 and 2021. At approximately 02:00 p.m. on 03/30/21, Licensed Vocational Nurse/QAPI/Quality Assurance Supervisor (LVN/QAPI/QA Supervisor) brought the surveyor a small, unlabeled, black binder stating, "This is all I can find." Review of the black binder revealed 19 pages, it included Agency forms as follows: -"Agency Name" review summary report for January thru June 2019. - A QAPI tracking Activities form. This form had no date or signatures but was with the summary report for January thru June 2019. - A QAPI Committee/Governing Board Meeting minutes for January thru June 2019. It was dated 10/20/19 and was signed by five agency employees, titles were not included after signatures. -Performance Improvement Project (PIP): "Diabetic Foot Care", there was no date on the form, but it was with the summary report for January thru June 2019. The PIP included the problem, but no results or raw data was included with the PIP. -There was no raw data to back up the January thru June 2019 summary report. -"Agency Name" review summary report for July thru December 2019. -A QAPI tracking Activities form. This form had no date or signatures but was with the summary report for July thru December 2019. - A QAPI Committee/Governing Board Meeting minutes for July thru December 2019. It was dated 02/19/20 and was signed by four agency employees, titles were not included after signatures. -There was no PIP. -There was no raw data to back up the July thru December 2019 summary report. Continue review of the small, unlabeled, black binder failed to include a QAPI program to measures, analyze and track quality indicators to assess care services, significant measures and operations of the Agency for 2020 and 2021. In an interview conducted on 03/30/21 at 02:40 p.m. with the LVN/QAPI/QA Supervisor, the Surveyor presented the above findings and asked if there was any raw data for the QAPI program for the first and second quarter of 2019, the LVN/QAPI/QA stated, "That's all I have." The Surveyor asked if the Agency had a Quality Assessment Performance Improvement (QAPI) program that addressed key indicators for the for the first and second quarter in 2020 and the first quarter in 2021. The LVN/QAPI/QA stated, "No that is all I can find." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Management of Quality Assurance Process Improvement Plan", it was numbered 1, but was not dated. It read in part: "The Quality Assessment Performance Improvement (QAPI) plan is to develop, implement, evaluate and maintain an effective ongoing, Agency wide, data driven QAPI program...timely identification of problems in patient care and deliver of care processes through concurrent review, with professional attention to adverse events and/or patterns. According to Texas Administrative Code, Title 40, Part 1, Chapter 97, Licensing Standards for Home and Community Support Services Agencies 97.287(a) (1) Quality Assessment and Performance Improvement (QAPI) Program: (1) An agency must maintain a QAPI Program that is implemented by a QAPI Committee. The QAPI Program must be ongoing, focused on client outcomes that are measurable, and have a written plan of implementation. The QAPI Committee must review and update or revise the plan of implementation at least once within a calendar year, or more often if needed. The QAPI Program must include: (A) a system that measures significant outcomes for optimal care. The QAPI Committee must use the measures in the care planning and coordination of services and events. The measures must include the following as appropriate for the scope of services provided by the agency: (i) an analysis of a representative sample of services furnished to clients contained in both active and closed records; (ii) a review of: (I) negative client care outcomes; (II) complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff; (III) infection control activities; (IV) medication administration and errors; and (V) effectiveness and safety of all services provided, including: (-a-) the competency of the agency's clinical staff; (-b-) the promptness of service delivery; and (-c-) the appropriateness of the agency's responses to client complaints and incidents; (iii) a determination that services have been performed as outlined in the individualized service plan, care plan, or plan of care; and (iv) an analysis of client complaint and satisfaction survey data; and (B) an annual evaluation of the total operation, including services provided under contract or arrangement. (i) An agency must use the evaluation to correct identified problems and, if necessary, to revise policies. (ii) An agency must document corrective action to ensure that improvements are sustained over time.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed and immediately corrected identified problems that directly or could potentially threaten the patient care and safety, in that the Agency did not have or complete a Performance improvement Project for 2019, 2020 and 2021. This failure could place the agency's active Licensed and Certified clients at risk of receiving inadequate care and of not having their needs met and problems corrected. The findings included: At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QA/LVN) the Surveyor requested the Agency's QAPI Manuals for 2019, 2020 and 2021. At approximately 02:00 p.m. on 03/30/21, Licensed Vocational Nurse/QAPI/Quality Assurance Supervisor (LVN/QAPI/QA Supervisor) brought the surveyor a small, unlabeled, black binder stating, "This is all I can find." Review of the black binder revealed 19 pages, it included an Agency form titled: "Performance Improvement Project (PIP): Diabetic Foot Care", there was no date on the form, but it was with a QAPI summary report for January thru June 2019. The PIP included the problem, but no investigation, no results or raw data was included with the PIP. Continued review of the small, unlabeled, black binder revealed that there was no documentation the agency conducted a review of a representative sample of services furnished, conducted an analysis of its services and reviewed negative patient care outcomes to identify reasons for a PIP to be chosen for the second quarter in 2019, the first and second quarter of 2020 and the first quarter of 2021. Further review of the small, unlabeled, black binder revealed that it failed to contain Performance Improvement Projects for the second quarter of 2019, the first and second quarters of 2020 and the first quarter of 2021. During an interview conducted on 03/30/21 at 02:40 p.m. with the LVN/QAPI/QA Supervisor the above findings were presented and after review of the small, unlabeled, black binder with the LVN/QAPI/QA, the Surveyor asked if the Agency had been able to identify and /or complete a Performance Improvement Project for the first quarter in 2019, the second quarter in 2019, the first and second quarter in 2020 and the first quarter in 2021. The LVN/QAPI/QA Supervisor stated "No, that is all we have." Review of the Agency's policy and procedure manual revealed a policy titled "Home Care Agency Quality Assessment Process Improvement Plan and Project (PIP)" it was numbered 3 and was not dated. It read in part: "The Agency provides a systematic mechanism whereby the quality of care, including both performance and process and effective utilization of services can be monitored. The program is designed to assess nursing and home health aide services, along with all aspects of the delivery process involved." Continued review of the Home Care Agency Quality Assessment Process Improvement Plan and Project (PIP)" policy read in part: "6. Performance Improvement Projects: The project will be documented and reviewed by the QAPI committee. The documentation will include the reason the project was chosen and show the projects progress and achievements through measurable evaluations of data gathered specifically for the project. Documentation will also reflect when changes or additions of measures must be utilized." Further review of the Home Care Agency Quality Assessment Process Improvement Plan and Project (PIP)" policy read in part: "The QAPI Committee will assess on an annual basis, the effectiveness of the Quality Assessment Performance Improvement Project."

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's Governing Body failed to ensure that the Quality Assessment Performance Improvement (QAPI) Committee met at least twice a year in 2020 and currently in 2021 to make sure that an ongoing program for quality improvement and patient safety was defined implemented and maintained. This failure could place the agency's 2 active Licensed and Certified patients at risk of receiving inadequate care and services from the agency's inability to trend patterns of competency of staff, services provided, promptness of service delivery and the agency's inability to implement measures to improve its services to its patients. The Findings Included: At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QA/LVN) the Surveyor requested the Agency's QAPI Manuals for 2019, 2020 and 2021. At approximately 02:00 p.m. on 03/30/21, Licensed Vocational Nurse/QAPI/Quality Assurance Supervisor (LVN/QAPI/QA Supervisor) brought the surveyor a small, unlabeled, black binder stating, "This is all I can find." Review of the black binder revealed 19 pages, it included two Agency forms as follows: - A QAPI Committee/Governing Board Meeting minutes for January thru June 2019. It was dated 10/20/19 and was signed by five agency employees, titles were not included after signatures. - A QAPI Committee/Governing Board Meeting minutes for July thru December 2019. It was dated 02/19/20 and was signed by four agency employees, titles were not included after signatures. Continue review of the small, unlabeled, black binder failed to include documentation of QAPI Committee Meetings conducted for the first and second quarter of 2020 and the first quarter of 2021. During an interview conducted on 03/30/21 at 02:40 p.m. with the LVN/QAPI/QA Supervisor, the Surveyor presented the above findings and asked if the Agency conducted QAPI Committee Meetings for the first and second quarter of 2020 and the first quarter of 2021. The LVN/QAPI/QA Supervisor stated "I don't know, all I have is what I gave you." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Executive Responsibilities", it was numbered 6, but was not dated. It read in part: "The Governing Body is responsible for ensuring a Quality Assurance Program and the Process..." Continued review of the Agency's Policy and Procedure manual revealed a policy titled "Rules and Regulations of the Quality Assessment Process Improvement Committee", it was numbered 2 and was not dated. It read in part: "The QAPI committee meets on a regular basis, no less than twice a year..." According to Texas Administrative Code, Title 26, Part 1, Chapter, Licensing Standards for Home and Community Support Services Agencies 558.287(c) Quality Assessment and Performance Improvement (QAPI) Program: Frequency of QAPI Committee meeting. The QAPI Committee must meet twice a year or more often if needed.

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: G-944; Administrator; The Administrator must... Based on record review and interview, the Agency failed to organize and direct the agency's ongoing functions as follows: 1. The Administrator failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal patient care outcomes for 2019, 2020 and currently in 2021. 2. The Administrator failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed and immediately corrected identified problems that directly or could potentially threaten the patient care and safety, in that the Agency did not have or complete a Performance improvement Project for 2019, 2020 and 2021. 3. The Administrator failed to ensure that the Quality Assessment Performance Improvement (QAPI) Committee met at least twice a year in 2020 and currently in 2021 to make sure that an ongoing program for quality improvement and patient safety was defined implemented and maintained. 4. The Administrator failed to review its written emergency preparedness and response plan at least once a year and after an actual emergency response to decide if the plan worked and to update it if needed for 2020 and currently in 2021. 5. The Administrator failed to ensure that the Agency's written emergency preparedness and response plan included a continuity of operation business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. 6. The Administrator failed to include or use in its emergency preparedness and response plan, procedures to triage patients that allows the agency to categorize patients into groups based on services provided; the need for the services; their ability to evacuate and the patients medical and psychiatric condition and home environment. 7. The Administrator failed to ensure that the agency's Emergency Preparedness and Response Plan included a communication plan that complied with 42 Code of Federal Regulation (CFR) 484.22(c), for 2019, 2020 and currently in 2021. 8. The Administrator failed to ensure that the agency's written Emergency Preparedness and Response Plan included procedures to release patient information in the event of a disaster for 2020 and currently in 2021. G-948: Administrator Responsible for Day-to-Day Operations; Based on record review and interview, the Administrator failed to manage the daily operations of the agency in that: 1. The Administrator failed to respect the patient's rights to have an established individualized Plan of Care (POC [ 485] ) for 1 of 2 (#1) active Agency Licensed and Certified patients and 1 of 5 (#6) discharged Licensed and Certified patients whose clinical records were reviewed. In that the certification period was completed without a Physician signed Plan of Care. 2. The Administrator failed to ensure the patients plan of care was executed as written for 4 of 7 ( #1, #2, #3 and #4) patients whose records were reviewed. -. Licensed Vocational Nurses (LVN) C did not complete the required Skilled Nurse Visits (SN) for Patient #1 and as ordered on the Plan of Care (POC). -. Registered Nurse (RN) B, RN C and Licensed Vocational Nurses (LVN) D, and E did not instruct Patient #2 and/or caregiver as ordered on the POC. -. LVN F did not instruct Patient #3 and/or caregiver as ordered on the POC. -. RN B, RN D, LVN E and LVN H did not instruct Patient #4 and/or caregiver as ordered on the POC. 3. The Administrator failed to enforce its written policy to ensure the effective exchange of information and coordination of patient services among all agency personnel providing care and services for 2 of 7 Patients (#1 and #2) whose records were reviewed.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview, the Administrator failed to organize and direct the agency's ongoing functions as follows: 1. The Administrator failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal patient care outcomes for 2019, 2020 and currently in 2021. 2. The Administrator failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed and immediately corrected identified problems that directly or could potentially threaten the patient care and safety, in that the Agency did not have or complete a Performance improvement Project for 2019, 2020 and 2021. 3. The Administrator failed to ensure that the Quality Assessment Performance Improvement (QAPI) Committee met at least twice a year in 2020 and currently in 2021 to make sure that an ongoing program for quality improvement and patient safety was defined implemented and maintained. 4. The Administrator failed to review its written emergency preparedness and response plan at least once a year and after an actual emergency response to decide if the plan worked and to update it if needed for 2020 and currently in 2021. 5. The Administrator failed to ensure that the Agency's written emergency preparedness and response plan included a continuity of operation business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. 6. The Administrator failed to include or use in its emergency preparedness and response plan, procedures to triage patients that allows the agency to categorize patients into groups based on services provided; the need for the services; their ability to evacuate and the patients' medical and psychiatric condition and home environment. 7. The Administrator failed to ensure that the agency's Emergency Preparedness and Response Plan included a communication plan that complied with 42 Code of Federal Regulation (CFR) 484.22(c), for 2019, 2020 and currently in 2021. 8. The Administrator failed to ensure that the agency's written Emergency Preparedness and Response Plan included procedures to release patient information in the event of a disaster for 2020 and currently in 2021. These failures resulted in the Agency failing to carry out, organize and supervise ongoing work under the Agency's policies and could have put the Agency's active patient at risk of receiving substandard care and services. The Findings Included: 1. At the Entrance conference on 03/30/21 at 10:27 a.m., with the Adm/DON, ADON, and the QA/LVN the Surveyor requested the Agency's QAPI Manuals for 2019, 2020 and 2021. In an interview conducted on 03/30/21 at 11:50 a.m. with the Adm/DON the Surveyor again requested the Agency's QAPI Manual's for 2019, 2020, and 2021. In an interview conducted on 03/30/21 at 12:30 p.m. with the Adm/DON, the Surveyor requested, for the third time, the Agency's QAPI Manual's for 2019, 2020 and 2021. In an interview conducted on 03/30/21 at 01:10 p.m. with the Adm/DON the Surveyor requested, for the fourth, the Agency's QAPI Manuals for 2019, 2020 and 2021. At approximately 02:00 p.m. on 03/30/21, Licensed Vocational Nurse/QAPI/Quality Assurance Supervisor (LVN/QAPI/QA Supervisor) brought the surveyor a small, unlabeled, black binder stating, "This is all I can find." Review of the black binder revealed 19 pages, it included Agency forms as follows: -"Agency Name" review summary report for January thru June 2019. - A QAPI tracking Activities form. This form had no date or signatures but was with the summary report for January thru June 2019. - A QAPI Committee/Governing Board Meeting minutes for January thru June 2019. It was dated 10/20/19 and was signed by five agency employees, titles were not included after signatures. -Performance Improvement Project (PIP): "Diabetic Foot Care", there was no date on the form, but it was with the summary report for January thru June 2019. The PIP included the problem, but no results or raw data was included with the PIP. -There was no raw data to back up the January thru June 2019 summary report. -"Agency Name" review summary report for July thru December 2019. -A QAPI tracking Activities form. This form had no date or signatures but was with the summary report for July thru December 2019. - A QAPI Committee/Governing Board Meeting minutes for July thru December 2019. It was dated 02/19/20 and was signed by four agency employees, titles were not included after signatures. -There was no PIP. -There was no raw data to back up the July thru December 2019 summary report. Continue review of the small, unlabeled, black binder failed to reveal a QAPI program to measures, analyze and track quality indicators to assess care services, significant measures and operations of the Agency for 2020 and 2021. In an interview conducted on 03/30/21 at 02:40 p.m. with the LVN/QAPI/QA Supervisor, the Surveyor presented the above findings and asked if there was any raw data for the QAPI program for the first and second quarter of 2019, the LVN/QAPI/QA stated, "That's all I have." The Surveyor asked if the Agency had a Quality Assessment Performance Improvement (QAPI) program that addressed key indicators for the for the first and second quarter in 2020 and the first quarter in 2021. The LVN/QAPI/QA stated, "No that is all I can find." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Management of Quality Assurance Process Improvement Plan", it was numbered 1, but was not dated. It read in part: "The Quality Assessment Performance Improvement (QAPI) plan is to develop, implement, evaluate and maintain an effective ongoing, Agency wide, data driven QAPI program...timely identification of problems in patient care and deliver of care processes through concurrent review, with professional attention to adverse events and/or patterns. Review of the Administrators/Director of Nursing's (Adm/DON) personal record revealed an Agency form titled "Job Description - Position Administrator", it was dated 11/01/17 and was signed by the Adm/DON. It read in part: "Responsibilities: 1) Organizes and directs the agency's ongoing functions." According to Texas Administrative Code, Title 40, Part 1, Chapter 97, Licensing Standards for Home and Community Support Services Agencies 97.287(a) (1) Quality Assessment and Performance Improvement (QAPI) Program: (1) An agency must maintain a QAPI Program that is implemented by a QAPI Committee. The QAPI Program must be ongoing, focused on client outcomes that are measurable, and have a written plan of implementation. The QAPI Committee must review and update or revise the plan of implementation at least once within a calendar year, or more often if needed. The QAPI Program must include: (A) a system that measures significant outcomes for optimal care. The QAPI Committee must use the measures in the care planning and coordination of services and events. The measures must include the following as appropriate for the scope of services provided by the agency: (i) an analysis of a representative sample of services furnished to clients contained in both active and closed records; (ii) a review of: (I) negative client care outcomes; (II) complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff; (III) infection control activities; (IV) medication administration and errors; and (V) effectiveness and safety of all services provided, including: (-a-) the competency of the agency's clinical staff; (-b-) the promptness of service delivery; and (-c-) the appropriateness of the agency's responses to client complaints and incidents; (iii) a determination that services have been performed as outlined in the individualized service plan, care plan, or plan of care; and (iv) an analysis of client complaint and satisfaction survey data; and (B) an annual evaluation of the total operation, including services provided under contract or arrangement. (i) An agency must use the evaluation to correct identified problems and, if necessary, to revise policies. (ii) An agency must document corrective action to ensure that improvements are sustained over time. 2. At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QA/LVN) the Surveyor requested the Agency's QAPI manuals for 2019, 2020 and 2021. At approximately 02:00 p.m. on 03/30/21, Licensed Vocational Nurse/QAPI/Quality Assurance Supervisor (LVN/QAPI/QA Supervisor) brought the surveyor a small, unlabeled, black binder stating "This is all I can find." Review of the black binder revealed 19 pages, it included an Agency form titled: "Performance Improvement Project (PIP): Diabetic Foot Care", there was no date on the form but it was with a QAPI summary report for January thru June 2019. The PIP included the problem, but no investigation, no results or raw data was included with the PIP. Continued review of the small, unlabeled, black binder revealed that there was no documentation the agency conducted a review of a representative sample of services furnished, conducted an analysis of its services and reviewed negative patient care outcomes to identify reasons for a PIP to be chosen for the second quarter in 2019, the first and second quarter of 2020 and the first quarter of 2021. Further review of the small, unlabeled, black binder revealed that it failed to contain Performance Improvement Projects for the second quarter of 2019, the first and second quarters of 2020 and the first quarter of 2021. During an interview conducted on 03/30/21 at 02:40 p.m. with the LVN/QAPI/QA Supervisor the above findings were presented and after review of the small, unlabeled, black binder with the LVN/QAPI/QA, the Surveyor asked if the Agency had been able to identify and /or complete a Performance Improvement Project for the first quarter in 2019, the second quarter in 2019, the first and second quarter in 2020 and the first quarter in 2021. The LVN/QAPI/QA Supervisor stated "No, that is all we have." Review of the Agency's policy and procedure manual revealed a policy titled "Home Care Agency Quality Assessment Process Improvement Plan and Project (PIP)" it was numbered 3 and was not dated. It read in part: "The Agency provides a systematic mechanism whereby the quality of care, including both performance and process and effective utilization of services can be monitored. The program is designed to assess nursing and home health aide services, along with all aspects of the delivery process involved." Continued review of the Home Care Agency Quality Assessment Process Improvement Plan and Project (PIP)" policy read in part: "6. Performance Improvement Projects: The project will be documented and reviewed by the QAPI committee. The documentation will include the reason the project was chosen and show the projects progress and achievements through measurable evaluations of data gathered specifically for the project. Documentation will also reflect when changes or additions of measures must be utilized." Further review of the Home Care Agency Quality Assessment Process Improvement Plan and Project (PIP)" policy read in part: "The QAPI Committee will assess on an annual basis, the effectiveness of the Quality Assessment Performance Improvement Project." 3. At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QA/LVN) the Surveyor requested the Agency's QAPI manuals for 2019, 2020 and 2021. At approximately 02:00 p.m. on 03/30/21, Licensed Vocational Nurse/QAPI/Quality Assurance Supervisor (LVN/QAPI/QA Supervisor) brought the surveyor a small, unlabeled, black binder stating, "This is all I can find." Review of the black binder revealed 19 pages, it included two Agency forms as follows: - A QAPI Committee/Governing Board Meeting minutes for January thru June 2019. It was dated 10/20/19 and was signed by five agency employees, titles were not included after signatures. - A QAPI Committee/Governing Board Meeting minutes for July thru December 2019. It was dated 02/19/20 and was signed by four agency employees, titles were not included after signatures. Continue review of the small, unlabeled, black binder failed to include documentation of QAPI Committee Meetings conducted for the first and second quarter of 2020 and the first quarter of 2021. During an interview conducted on 03/30/21 at 02:40 p.m. with the LVN/QAPI/QA Supervisor, the Surveyor presented the above findings and asked if the Agency conducted QAPI Committee Meetings for the first and second quarter of 2020 and the first quarter of 2021. The LVN/QAPI/QA Supervisor stated, "I don't know, all I have is what I gave you." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Executive Responsibilities", it was numbered 6, but was not dated. It read in part: "The Governing Body is responsible for ensuring a Quality Assurance Program and the Process..." Continued review of the Agency's Policy and Procedure manual revealed a policy titled "Rules and Regulations of the Quality Assessment Process Improvement Committee", it was numbered 2 and was not dated. It read in part: "The QAPI committee meets on a regular basis, no less than twice a year..." According to Texas Administrative Code, Title 26, Part 1, Chapter, Licensing Standards for Home and Community Support Services Agencies 558.287(c) Quality Assessment and Performance Improvement (QAPI) Program: Frequency of QAPI Committee meeting. The QAPI Committee must meet twice a year or more often if needed. 4. At the Entrance conference on 03/30/21 at 10:27 a.m., with the Administrator / Director of Nursing (Adm/DON), Alternate Director of Nursing (ADON), and the Quality Assurance Licensed Vocational Nurse (QA/LVN) the Surveyor requested the Agency's Emergency Preparedness manuals for 2019, 2020 and 2021, and an Employee list with titles and hire dates. On 03/30/21 at approximately 11:00 a.m. the Adm/DON brought the surveyor the employee list with titles and hire dates. In an interview conducted on 03/30/21 at 11:50 a.m. with the Adm/DON the Surveyor again requested the Agency's Emergency Preparedness Manuals for 2019, 2020, and 2021. In an interview conducted on 03/30/21 at 12:30 p.m. with the Adm/DON, the Surveyor requested, for the third time, the Agency's Emergency Preparedness Manual 2019, 2020 and 2021. At 01:31 p.m. the ADON brought the Surveyor an Emergency Preparedness Manual, one binder, the ADON stated "I know that it's not done like it is supposed to be." Review of the Agency's Emergency Preparedness manual included an agency form titled "Emergency Preparedness and Response Plan." It had a revision date of 03/19. The Emergency Preparedness Plan was 15 pages long. On page 15 was an Agency form titled "Agency Name Personal Assistance Service Telephone Tree." There was no other telephone tree in the plan. There were no Registered Nurses listed on the tree, and the employee list did not match the employee list with titles that the Surveyor requested and received. Continued review of the Agency's Emergency Preparedness Manual failed to contain documentation of an emergency preparedness and response plan that comprehensively describes the Agency's approach to a disaster for 2020 and currently in 2021. Further review of the Agency's Emergency Preparedness Manual failed to contain an annual or bi-annual review of the Emergency Preparedness plan to evaluate its effectiveness for 2020 and currently in 2021. During an interview on 03/31/21 at 08:45 a.m. with the Alternate Director of Nursing (ADON), the surveyor presented the above findings. After review of the Emergency Preparedness Plan, the ADON stated "Okay, I know we don't have it." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Emergency Preparedness", it was numbered 19, but had no date. It read in part: "The Agency will develop and implement an emergency preparedness and response plan that comprehensively describes the Agency's approach to a disaster..." Continued review of the Emergency Preparedness policy read in part: "The Emergency Preparedness and Response Plan will be reviewed annually and after each actual emergency." 5. Based on record review and interview, the Agency's written emergency preparedness and response plan failed to include a continuity of operation business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. This failure could place the Agency's 2 active Licensed and Certified patients at risk of harm from the possibility of the agency being unable to function following a disaster. The Findings Included: Review of the Agency's Emergency Preparedness manual included an agency form titled "Emergency Preparedness and Response Plan" it was dated 03/19. Continued review of the Emergency Preparedness and Response Plan revealed a "Continuation of Business Plan" on page 4. It read in part: "The Agency's goal of the Continuation of Operations Business plan is to safely provide clients with continued authorized services as long as possible and with minimal disruption of schedule." Review of the agency's Emergency Preparedness Manual failed to reveal documentation of a continuity of operations business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. During an interview on 03/31/21 at 08:45 a.m. with the ADON, the Surveyor asked if the agency's Emergency Preparedness Plan included a Continuity of Operations Business Plan that addressed emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and currently in 2021. After review of the Emergency Preparedness Manual and the Emergency Preparedness Plan, the ADON stated "Okay, I understand that it's not complete." Review of the Agency's Policy and Procedure manual revealed a policy titled "Emergency Preparedness" it was numbered 19, but was not dated. It read in part: "The continuation of Operations Plan will include: emergency financial needs, essential functions for client services, critical personnel and how to return to normal operations as quickly as possible." 6. Review of the Agency's Emergency Preparedness and Response Plan failed to include a current list of patients whose triage category had been assessed and incorporated into the emergency preparedness plan for 2019, 2020 and currently in 2021, in that the Patient list had been omitted from the plan for 2019, 2020 and 2021. During an interview on 03/31/21 qt 08:45 a.m. with the Alternate Director of Nursing (ADON), the Surveyor asked if the agency's Emergency Preparedness and Response Plan included a current list of patients whose triage category had been assessed and incorporated into the emergency preparedness plan. After review of the Emergency Preparedness Manual, and the Emergency Preparedness Plan for 2019, 2020 and currently in 2021, the ADON stated "No." Review of the Agency's Policy and Procedure manual revealed a Policy titled "Emergency Preparedness." It was numbered 19 but was not dated. It read in part: "(12) The triage system will allow for quick access to recorded information about an active patient triage category in the event of an emergency..." Continued review of the Emergency Preparedness." policy read in part: "(9) Patients will be triaged in accordance with the following: a) Services Provided by the Agency b) Patients need for continuity of the services provided by the agency and c) Availability of someone to assume responsibility for the Patients emergency response plan if needed by the patients." Further review of the policy titled "Emergency Preparedness" policy read in part: " The Agency must complete an internal review of the plan at least annually..." 7. Continued review of the Agency's Emergency Preparedness Manual failed to reveal documentation that the Agency's Emergency Preparedness Plan included a Communication Plan that complied with 42 Code of Federal Regulation (CFR) 484.22(c) for 2019, 2020 and 2021. During an interview on 03/31/21 at 08:45 a.m. with the Alternate Director of Nursing (ADON), the Surveyor presented the above findings and asked if there was documentation of the Communication Plan that the Agency had developed for the Emergency Preparedness Plan for 2019, 2020 and currently in 2021 that complied with 42 Code of Federal Regulation (CFR) 484.22(c). The ADON stated: "No." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Emergency Preparedness", it was numbered 19 and was not dated. It read in part: ""d. The Agency's written Emergency Preparedness and response plan must describe the following: 4. Procedures for communicating with staff, clients or persons responsible for a client's emergency response plan; local, state and federal emergency management agencies; and other entities including the Health and Human Services Commission and other healthcare providers and suppliers..." Continued review of the Emergency Preparedness policy read in part: "The Emergency Preparedness and Response Plan will be reviewed annually and after each actual emergency." According to the Code of Federal Regulations (CFR) § 484.22 (c) "Communication plan. The HHA must develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all the following: (1) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually] The communication plan must include all the following: Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other [facilities]. (v) Volunteers. (2) Contact information for the following: (i) Federal, State, tribal, regional, or local emergency preparedness staff. (ii) Other sources of assistance. (3) Primary and alternate means for communicating with the HHA's staff, Federal, State, tribal, regional, and local emergency management agencies. (4) A method for sharing information and medical documentation for patients under the HHA's care, as necessary, with other health care providers to maintain the continuity of care. (5) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). (6) A means of providing information about the HHA's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee." 8. Review of the Agency's Emergency Preparedness Manual included an agency form titled "Emergency Preparedness and Response Plan." It had a revision date of 03/19 and it included Agency Drills and Drill Performance Evaluations from 2019, 2020 and 2021. Continued review of the Emergency Preparedness and Response plan read in part: "4. Privacy and Disclosure of Private Health Information (a) in accordance with the Agency's Policy the Agency will only disclose information to assist the patient in an emergency and will disclose only the minimum necessary to assist the patient..." Further review of the Emergency Preparedness and Response plan failed to contain documentation of a method for sharing information and medical documentation for patients under the Agency's care, as necessary, with the patients and other health providers to maintain the continuity of care, or as a means of providing information about the general condition and location of patients under the Agency's care. During an interview on 03/31/21 at 08:45 a.m. with the Alternate Director of Nursing (ADON), the Surveyor presented the above findings and asked if the agency had a written emergency preparedness and response plan that included procedures to release client information in the event of a disaster for 2020 and currently in 2021. The ADON stated, "No." Review of the agency's Policies and Procedures Manual revealed a policy form titled "Emergency Preparedness" it was numbered 19 but was not dated. It read in part: "3. The plan will include the following: include procedures to release patient information in the event of a disaster."

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to manage the daily operations of the agency in that: 1. The Administrator failed to respect the patient's rights to have an established individualized Plan of Care (POC [ 485]) for 1 of 2 (#1) active Agency Licensed and Certified patients and 1 of 5 (#6) discharged Licensed and Certified patients whose clinical records were reviewed. In that the certification period was completed without a Physician signed Plan of Care. 2. The Administrator failed to ensure the patients plan of care was executed as written for 4 of 7 (#1, #2, #3 and #4) patients whose records were reviewed. - Licensed Vocational Nurses (LVN) C did not complete the required Skilled Nurse Visits (SN) for Patient #1 and as ordered on the Plan of Care (POC). - Registered Nurse (RN) B, RN C and Licensed Vocational Nurses (LVN) D, and E did not instruct Patient #2 and/or caregiver as ordered on the POC. - LVN F did not instruct Patient #3 and/or caregiver as ordered on the POC. - RN B, RN D, LVN E and LVN H did not instruct Patient #4 and/or caregiver as ordered on the POC. - LVN I checked Patient #7's Pulse Oxygenation Level without an order. The Administrator failed to enforce its written policy to ensure the effective exchange of information and coordination of patient services among all agency personnel providing care and services for 2 of 7 Patients (#1 and #2) whose records were reviewed. The Findings Included: 1. Review of Active Patient #1's electronic clinical record for the completed Certification Period of 01/29/21 thru 03/29/21, showed diagnoses of Transient Ischemic Attacks (TIA's or mini strokes) and A Pressure Ulcer Stage 2. Review of the POC included a skilled nurse (SN) visit frequency of one time per day for 60 days. It also included Wound Care orders, many Teachings, Treatments and New Medications. Continued review of the POC revealed that the Attending Physician had not signed the POC for the certification period of 01/29/21 thru 03/29/21. During an interview conducted on 03/31/21 at 09:24 a.m. with Licensed Vocation Nurse/Quality Assurance (LVN/QA) G, the surveyor presented the above finding and asked her to check if they had the signed POC for Patient #1's Certification Period of 01/29/21 thru 03/29/21. LVN/QA G checked her records and stated "No, we don't have it." On 03/31/21 at 11:17 a.m. the AA/Owner brought the Surveyor a signed Physician copy of Patient #1's POC for Certification Period of 01/29/21 thru 03/29/21. The AA/Owner stated "They told me you were looking for this, okay now? The Surveyor explained that the Agency nurses provided care for the entire certification period without a physician's order to do so. The Physician dated the POC 03/31/21, after the certification period had ended and after surveyor pointed out the failure. Review of Discharged Patient #6's electronic clinical record for the completed Certification Period of 08/04/20 thru 10/02/20, showed diagnoses of High Blood Pressure and Atrial Fibrillation (irregular heart beat). Review of the POC included a skilled nurse (SN) visit frequency of one time per week for one week, then 2 times per week for one week and then one time per week for seven weeks. It also included Physical Therapy orders, many teachings, treatments and New Medications. Continued review of the POC revealed that the Attending Physician had not signed the POC for the certification period of 08/04/20 thru 10/02/20. Also reviewed for Discharge Patient #6 was the completed Certification Period of 06/05/20 thru 08/03/20, it showed diagnoses of High Blood Pressure and Hyperlipidemia (a high concentration of fat in the blood). Review of the POC included a SN visit frequency of one time per week for one week, then 2 times per week for one week and then one time per week for seven weeks. Continued review of the POC revealed that the Attending Physician had not signed the POC for the certification period of 06/05/20 thru 08/03/20. Discharged Patient #6 went through two complete certification periods without an Attending Physician signed POC. During an interview on 04/01/21 at 09:24 a.m with Licensed Vocation Nurse/Quality Assurance (LVN/QA) G, the surveyor presented the above findings and asked her to check to see if they had signed Plans of Care for discharged Patient #6 for the completed Certification Periods of 08/04/20 thru 10/02/20 and 06/05/20 thru 08/03/20. LVN/QA G checked her records and stated, "No we don't have them, I am checking with the doctor now." During an interview and concurrent record review conducted on 04/01/21 at 11:36 a.m. with the Administrator/Director of Nursing, the Alternate Director of Nursing and the Alternate Administrator/Owner the Surveyor presented the above findings and asked if the Plans of Care for Patient #1 and Patient #6 had been signed by the Physician. After review of the 3 Plans of Care respectively, the Adm/DON stated "Ah, no they weren't signed." They agreed that Patient #1 and Patient #6 did not get the chance to participate in their care when it came to establishing and revising their individual Plans Of Care. Review of the Agency's Policy and Procedure manual revealed a policy titled "Patient Rights and Responsibilities." It was not numbered but had a revision date of 02/2016. It read in part: "The patient has the right to be informed in advance about the care to be furnished and of any changes in the care to be furnished." Continued review of the Patient Rights and Responsibilities policy read in part: "The patient has the right to participate in the planning of the care or treatment and in planning changes in the care or treatment." Continued review of the Agency's policy and procedure Manual revealed a policy titled "Plan of Care/Care Plan", it was numbered 7, but was not dated. It read in part: "Skilled care follows a written Plan of Care (485) established and reviewed by a Doctor of Medicine..." Continued review of the Plan of Care/Care Plan policy read in part: "5. The Plan of Care will be developed following the assessment and hand carried, uploaded or mailed to Physician for signature. The written POC must be signed by the physician and returned to the agency." Further review of the Plan of Care/Care Plan policy read in part: "7. Care follows the written physician plan of care." Still further review of the Plan of Care/Care Plan policy read in part: "8. A Registered Nurse prepares the POC and submits to the Physician for signature." Continued review of the Plan of Care/Care Plan policy read in part: "10. The POC shall be reviewed and revised by the Attending Physician." Further review of the Plan of Care/Care Plan policy read in part: "11. The Patient will be informed of any changes in the POC before the changes are made." Further Review of the Agency's Policy and Procedure Manual revealed a policy titled "Acceptance of Physician Verbal Orders", it was numbered 8, but was not dated. It read in part: "The Physician must order all treatments and care furnished in the licensure category of licensed and certified home health services and licensed home health services." Review of the Administrators/Director of Nursing's (Adm/DON) personel record revealed an Agency form titled "Job Description - Position Administrator", it was dated 11/01/17 and was signed by the Adm/DON. It read in part: "The Administrator is responsible for implementing and supervising the administrative policies of the agency and administratively supervises the provision of all services. 2. Review of the Administrator/Director of Nursing's (Adm/DON) personnel record, revealed a Job description that was dated 01/15/18 and signed by the Adm/DON. It read in part: "3. Assure the development implantation and updates of the individualized plans of care." Review of active Patient #1's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 01/29/21 thru 03/29/21 with diagnoses of Transient Ischemic Attacks (mini strokes) and Pressure Ulcer Stage 2. The POC included a skilled nurse (SN) visit frequency of twice a week for every day times 60 days. Continued review of the POC revealed that it was not signed by the physician. Further review of Patient #1's electronic clinical record failed to reveal any documentation for SN visits dated 03/06/21, 03/07/21, 03/27/21 and 03/28/21. They were left blank. The four SN visits that were left blank, 03/06/21, 03/07/21, 03/27/21 and 03/28/21 were signed by LVN C. In an interview and concurrent record review conducted on 04/01/21 at 11:36 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the four blank SN visit notes to the Adm/DON and asked if there was any completed documentation for those four SN visits. The Adm/DON Stated "No, there isn't. -Review of active Patient #2's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 12/16/21 thru 02/13/21 with diagnoses of Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The POC included a skilled nurse (SN) visit frequency of twice a week for one week and one time per week for eight weeks. The POC included an order for the Skilled Nurse (SN) to assess the integumentary status at ever visit. Review of the SN visit note dated 01/04/21 and signed by LVN E noted that Patient #2 had developed a rash. Review of Patient # 2's clinical record failed to include documentation that coordination of care, concerning the rash, was done with the Agency and Patient #2's attending physician. The POC included orders for the Skilled Nurse (SN) to perform a total of 8 skilled nursing visits and orders for teaching/instruction of Pain Control and Prevention, Nebulizer Cleaning, High Blood Pressure, Signs and Symptoms of Infection and the Specific Medications Albuterol and Metoprolol. Continued review of the POC revealed that it was signed by the physician on 01/29/21. The SN visit signed by RN B was dated 01/11/21. The SN visit signed by RN C was dated 02/22/21, The SN visits signed by LVN D were dated 12/21/20, 12/28/20, 01/20/21 and 01/25/21. The SN visits signed by LVN E were dated 01/04/21 and 02/05/21. All 8 of the SN Visit Notes failed to contain documentation that Patient #2 and/or the Caregiver were instructed on Pain Control and Prevention, Nebulizer Cleaning, High Blood Pressure, Signs and Symptoms of Infection and the Specific Medications Albuterol and Metoprolol. In an interview and concurrent record review conducted on 04/01/21 at 11:44 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings the teachings were pointed out, the Surveyor asked the Adm/DON if Patient #2 and/or the Caregiver had been taught the following: Pain Control and Prevention, Nebulizer Cleaning, High Blood Pressure, Signs and Symptoms of Infection and the Specific Medications Albuterol and Metoprolol. After reviewing the Adm/DON stated "No, I see." The Surveyor pointed out the SN visit note dated 01/04/21 and asked if there was any coordination of care documentation concerning the rash with the Agency and Patient #2's physician. The Adm/DON stated "Oh, I see, there isn't." -Review of discharged Patient #3's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 10/10/20 thru 12/08/20 with diagnoses of Type 2 Diabetes Mellitus and Chronic Pressure Ulcer. The POC included a skilled nurse (SN) visit frequency of three times a week for eight weeks, and a frequency change during the certification period on 10/28/20 of one time per week for 6 weeks, for a total of 14 SN visits. The POC included orders for the Skilled Nurse (SN) to perform a total of 14 skilled nursing visits and orders for teaching/instruction on the Disease Process for Type 2 Diabetes and Chronic Pressure Ulcer, Falls and Safety and Infection Control. Continued review of the POC revealed that it was signed by the physician. The SN visits signed by LVN F were dated 10/11/20, 10/13/20, 10/14/20, 10/16/20, 10/19/20, 10/21/20, 10/23/20, 10/26/20, 10/28/20, 11/04/20, 11/11/20, 11/18/20, 11/25/20 and 12/01/20. All 14 for the SN Visit Notes failed to contain documentation that LVN F instructed Patient #3 and/or the caregiver on the Disease Process for Type 2 Diabetes and Chronic Pressure Ulcer, Falls and Safety and Infection Control. In an interview and concurrent record review conducted on 04/01/21 at 11:46 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings the teachings were pointed out, the Surveyor asked the Adm/DON if Patient #3 and/or the Caregiver that been taught the following: the Disease Process for Type 2 Diabetes and Chronic Pressure Ulcer, Falls and Safety and Infection Control. After reviewing the Adm/DON stated "Okay, No, I understand." -Review of discharged Patient #4's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 02/10/20 thru 04/07/20 with diagnoses of Type 2 Diabetes Mellitus and Chronic Pressure Ulcer. The POC included a skilled nurse (SN) visit frequency one time per week for nine weeks. Review of Patient #4's clinical record revealed documentation that Patient #4 was prone to Urinary Tract Infections. The POC included orders for the Skilled Nurse (SN) to perform a total of 9 skilled nursing visits and orders for teaching/instruction on Genitourinary Status, Prevention of Urinary Tract Infections and Infection Control. Continued review of the POC revealed that it was signed by the physician on 03/06/20. The SN visit signed by RN B was dated 02/06/20. The SN visit signed by RN D was dated 04/10/20. The SN visits signed by LVN E were dated 02/20/20 and 03/26/20. The SN visits signed by LVN H were dated 02/15/20, 03/10/20, 03/15/20, 03/18/20 and 04/02/20. All 9 of the SN Visit Notes failed to contain documentation that Patient #4 and/or the caregiver was instructed on the Genitourinary Status, Prevention of Urinary Tract Infections and Infection Control. In an interview and concurrent record review conducted on 04/01/21 at 11:51 a.m. with the Adm/DON, the ADON and the AA/Owner the Surveyor presented the above findings the teachings were pointed out, the Surveyor asked the Adm/DON if Patient #4 and/or the Caregiver had been taught the following: Genitourinary Status, Prevention of Urinary Tract Infections and Infection Control. After reviewing the Adm/DON stated "No, okay, I understand." - Review of discharged Patient #7's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 03/05/20 thru 05/03/20 with diagnoses of Type 2 Diabetes Mellitus with foot ulcer and Cellulitis of left lower limb. The POC included a skilled nurse (SN) visit frequency of one time per day for 60 days. Patient #7 was discharged on 03/17/20. The total Skilled Nurse visits for this certification period were 11. Review of the POC revealed that it was signed by the physician on 04/08/20. The POC did not include orders for the SN to assess Pulse Oximetry. (A noninvasive and painless test that measures oxygen levels in blood). The SN visit signed by LVN I were dated 03/06/20, 03/07/20, 03/08/20, 03/09/20, 03/10/20, 03/11/20, 03/12/20, 03/13/20, 03/14/20, 03/15/20 and 03/16/20. Ten of the eleven skilled nurse visits signed by LVN I, 03/06/20, 03/07/20, 03/09/20, 03/10/20, 03/11/20, 03/12/20, 03/13/20, 03/14/20, 03/15/20 and 03/16/20, included an assessment of Pulse Oximetry. 03/08/20 was a missed visit and documentation of the Missed Visit was completed by LVN I. In an interview and concurrent record review conducted on 04/01/21 at 11:56 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings and pointed out that there was no order on the POC for Pulse Oximetry for Patient #7, after Review the Adm/DON stated "There isn't, okay no order." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Plan of Care/Care Plan", it was numbered 7, but was not dated. It read in part: "Skilled care follows a written plan of care (485) established and periodically reviewed by a doctor..." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Clinical Record" it was numbered 19 but was not dated. It read in part: "The Agency will maintain a client record system to assure that the care and services provided to each client is completely and accurately documented, readily available and systematically organized to facilitate the compilation and retrieval of information." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Plan of Care/Care Plan", it was numbered 7, but was not dated. It read in part: "Skilled care follows a written plan of care (485) established and periodically reviewed by a doctor..." Review of the Agency's Policy and Procedure Manual revealed a Policy titled "Clinical Record" it was numbered 19 but was not dated. It read in part: "The Agency will maintain a client record system to assure that the care and services provided to each client is completely and accurately documented, readily available and systematically organized to facilitate the compilation and retrieval of information." 3. -Review of active Patient #1's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 01/29/21 thru 03/29/21 with diagnoses of Transient Ischemic Attacks (mini strokes) and Pressure Ulcer Stage 2. The POC included a skilled nurse (SN) visit frequency of twice a week for every day times 60 days. Continued review of the POC revealed that it was not signed by the physician. Further review of Patient #1's electronic clinical record failed to reveal any documentation for SN visits dated 03/06/21, 03/07/21, 03/27/21 and 03/28/21. They were left blank. The four SN visits that were left blank, 03/06/21, 03/07/21, 03/27/21 and 03/28/21 were signed by LVN C. Still further review of Patient #1's electronic clinical record failed to reveal any documentation of coordination of care with the Agency Staff or Client #1's Physician as to why the SN visits were omitted. In an interview and concurrent record review conducted on 04/01/21 at 11:36 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the four blank SN visit notes to the Adm/DON and asked if there was any completed documentation for those four SN visits. The Adm/DON Stated "No, there isn't. The Surveyor asked if there was any documentation of Coordination of Care with the Agency or Patient #1's Physician. After reviewing the Adm/DON stated "No, there isn't." -Review of active Patient #2's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 12/16/21 thru 02/13/21 with diagnoses of Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The POC included a skilled nurse (SN) visit frequency of twice a week for one week and one time per week for eight weeks. The POC included an order for the Skilled Nurse (SN) to assess the integumentary status at ever visit. Review of the SN visit note dated 01/04/21 and signed by LVN E noted that Patient #2 had developed a rash. Review of Patient # 2's clinical record failed to include documentation that coordination of care, concerning the rash, was done with the Agency and Patient #2's attending physician. Continued review of the POC revealed that it was signed by the physician on 01/29/21. In an interview and concurrent record review conducted on 04/01/21 at 11:44 a.m. with the Administrator/Director of Nursing (Adm/DON), the Alternate Director of Nursing (ADON) and the Alternate Administrator/Owner (AA/Owner) the Surveyor presented the above findings. The Surveyor pointed out the SN visit note dated 01/04/21 and asked if there was any completed coordination of care documentation concerning the rash with the Agency and/or Patient #2's physician. The Adm/DON stated "Oh, I see, there isn't." Review of the Agency Policy and Procedure Manual revealed a policy titled "Coordination of Patient care with other health care providers and Agency Staff ", it was numbered 11, but was not dated. It read in part: "Quality coordination of care is provided and communicated to all patients, representatives and caregivers to ensure the patients' needs are met through an effective interchange and reporting with other health care providers providing services to patients and with the Agency's Staff. Coordination of care with Agency Staff will be accomplished through case conferences and other methods of communication..." Continued review of the Coordination of Patient care with other health care providers and Agency Staff policy read in part: "Documentation of Coordination of Care will be signed and dated and filed in the patients record." Continued review of the Agency's Policy and Procedure Manual revealed a policy titled "Communication with the Physician" it was numbered 12 but was not dated. It read in part: "All communication to or from physicians regarding a patient's condition and treatment will be documented in the patient's clinical record. Documentation must include who was spoken to, what information was reported, response, and any orders received and follow-up." Continued review of the Communication with the Physician policy read in part: "Information relevant to the patient's condition and treatment will be reported to the physician documented and physician orders generated when applicable may include but not limited to: C) Findings outside established parameters, E) Significant signs and symptoms associated with the patients' medical diagnoses or with yet undetected or unconfirmed diagnoses and I) Omission of services, treatments or diagnostic studies ordered." According to Texas Administrative Code, Title 26, Part 1, Chapter 558, Licensing Standards for Home and Community Support Services Agencies. "An agency must adopt and enforce a written policy regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of patient services among: (1) all agency personnel providing care and services, whether the care and services are provided directly or under arrangement;