Every finding on record at Paradise Home Health Group, Inc.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted from 11/18/2024 to 11/22/2024. Unduplicated admissions – 196 Active census – 108 Sample size - 7 Home visits – 3 On 11/21/2024, at 12:22 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Director of Patient Care Services (DPCS) related to the home health agency (HHA) failure to ensure an update of the comprehensive assessment (or the Recertification assessment, the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) were completed for four of seven sampled patients (Patient 3, Patient 4, Patient 5, and Patient 6). On 11/21/2024 at 12:33 p.m., a second IJ was called in the presence of the agency's DPCS related to the HHA’s failure to ensure a plan of care (or POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was developed and implemented for five of seven patients (Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). On 11/21/2024, at 12:45 p.m., the third IJ was called in the presence of the agency’s DPCS related to the HHA failure to provide an updated comprehensive assessment, the current plan of care, and nursing visit clinical notes for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6. As a result, the non-compliance resulted in incomplete clinical records that does not reflect patients' current condition and needs which likely to cause unidentified needs, serious injury, harm, impairment, or death to a patient. On 11/22/2024, at 1:30 p.m., the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) for the three IJs. On 11/22/2024, at 1:50 p.m., the survey team completed the survey tasks and conducted an exit conference, in the presence of the DPCS, Office manager and a volunteer, with the three IJs not removed. On 12/26/2024 the HHA submitted the IJ removal plans and the survey team reviewed and accepted as follow: IJ removal plan for G546: 1.On 11/26/2024, the HHA completed the comprehensive assessments for Patient 3, Patient 4, Patient 5, and Patient 6. 2.On 11/26/2024, the HHA conducted a full audit of all active patient records. 3. On 11/26/2024, the HHA conducted training for all clinical staff regarding documentation. 4.On 12/17/2024, the HHA completed the comprehensive assessments for Patient 9 and Patient 13. On 12/26/2024, at 12 pm, the Department removed the IJ situation in the presence of the ADM and Volunteer after onsite verification of the HHA's IJ removal plan through observation, interview, and record review. IJ removal plan for G572: 1.On 11/26/2024, the HHA completed the plan of care for Patient 2, Patient 3, Patient 5, and Patient 6 to reflect their current health status, needs, and goals of care. 2.On 11/26/2024, the HHA audited 108 records and identified that eleven patients had incomplete plan of care and updated the plan of care. 3. On 11/26/2024, the HHA conducted training for all clinical staff regarding documentation. 4.On 12/17/2024, the HHA developed and updated the plan of care for Patient 9 and Patient 13. On 12/26/2024, at 12:03 pm, the Department removed the IJ situation in the presence of the ADM and Volunteer after onsite verification of the HHA's IJ removal plan through observation, interview, and record review. IJ removal plan for G1012: 1.On 11/26/2024, the HHA completed the comprehensive assessments, plan of care, and missing nursing visit clinical notes for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6. 2.On 11/26/2024, the HHA completed an audit of 108 records and identified that nine patients had incomplete comprehensive assessments. 3. On 11/26/2024, the HHA identified 88 patients had incomplete visit notes and completed the visit notes. 4. On 11/26/2024, the HHA conducted training for all clinical staff regarding documentation. 5.On 12/17/2024, the HHA identified 71 patients with incomplete comprehensive assessments and completed the assessments. On 12/26/2024, at 12:05 pm, the Department removed the IJ situation in the presence of the ADM and Volunteer after onsite verification of the HHA's IJ removal plan through observation, interview, and record review. The following Conditions of Participation (COP) were not met: 484.55 Comprehensive assessment of patients 484.60 Care planning, coordination of services, and quality of care 484.105 Organization and administration of services 484.110 Clinical records

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure one of seven patient’s (Patient 1) was provided notification of their discharge from home health services. This failure resulted in Patient 1 unable to obtain outpatient physical therapy services and to experience continued lower back pain with a pain level of 8 (0= no pain, 10=severe pain) due to delayed care of physical therapy services. Findings: During a record review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 8/8/2024, with a primary diagnosis of essential (primary) hypertension (high blood pressure) and a secondary diagnosis of sarcopenia (age-related progressive loss of muscle mass and strength). The Face Sheet indicated Patient 1’s primary physician was Primary Physician (PP). During a record review of Patient’s Home Health Certification and Plan of Care (POC) for the certification period starting from 10/7/2024 to 12/05/2024, the POC indicated Patient 1 had diagnosis of hypertension, sarcopenia, and polyosteoarthritis (a type of arthritis that affects multiple joints at the same time, causing cartilage and bone to degenerate). The POC indicated that Patient 1 was admitted to the HHA with Skilled Nurse (SN) frequency visits of twice a week for two weeks and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a telephone interview on 11/19/2024 at 8:34 a.m., Family Member (FM1) stated Patient 1 had not received any discharge documentation or a call back from the home health agency. FM1 stated they called the agency multiple times, left messages, and that the HHA had not called back. FM1 stated that Patient 1 had scoliosis (S-curvature of the spine) in her lower back, and it caused her pain all the time. FM1 stated Patient 1 received an order for physical therapy from her orthopedic surgeon (a medical professional who specializes in diagnosing and treating diseases and injuries of the musculoskeletal system) at an outpatient physical therapy clinic but was not able to be admitted because Patient 1 was not discharged from the home health agency. FM1 stated that License Vocational Nurse (LVN3) visited Patient 1 at their new address and that they told LVN3 that they wanted to be discharged so Patient 1 could go to another physical therapist. During a telephone interview on 11/19/2024 at 9:15 a.m., Patient 1 stated that she had pain in her lower back. Patient 1 was asked to describe her pain and what her pain level was on a pain scale of 0 to 10 (0=no pain, 10=worst pain), Patient 1 stated that it was sharp and constant with a pain level of 8. Patient 1 stated that Licensed Vocational Nurse (LVN3) was the only nurse that visited her. During an interview on 11/20/2024 at 10:54 a.m., LVN3 stated the last time she visited Patient 1 was in the beginning of October 2024. LVN3 stated that she had visited Patient 1 in a skilled nursing facility several times and then the last time when Patient 1 moved into a mobile home. LVN3 stated FM1 asked that Patient 1 be discharged from home health services so she could start outpatient physical therapy with another physical therapist. LVN3 stated that Patient 1 was not able to be on outpatient physical therapy and home health services at the same time. LVN3 stated the Patient 1’s doctor called her three weeks ago and asked if the HHA discharged Patient 1, and LVN3 told her that the patient was discharged. During an interview and record review on 11/22/2024 at 10:30 a.m., with the Director of Patient Care Services (DPCS), Patient 1’s Orders (section in electronic chart that shows file for physician orders and the plan of care), Nursing Visit, and Communication notes on the electronic chart were reviewed. The DPCS stated there were no communication notes regarding Patient 1’s request to be discharged, no physician order for discharge, or and there was no discharge summary with patient discharge instruction/notification. During an interview and record review on 11/22/2024 at 10:40 a.m., with the DPCS, Patient 1’s OASIS-E Discharge assessment was reviewed. The discharge assessment indicated that the patient was discharged on 10/10/2024 and that a written notice was provided for the patient. The DPCS stated that Patient 1 was an office discharge, and the discharge assessment was not correct. The DPCS stated that the Patient was not visited by a nurse and not provided a written notice. The DPCS stated that if there was an office discharge, the patient’s referring physician should be notified and a copy of the patient discharge instructions/notification forms should be mailed to the patient. The DPCS stated that it was the patient’s right to be discharged and to be notified that they are discharged from home health services. During a record review of the HHA’s (undated) policy and procedure titled, “Patient Bill of Rights,” the policy indicated that each patient will be an active, informed participant in his/her plan of care. The policy indicated that the Patient Bill of Rights statement defines the right of the patient to…M. Be able to refuse care or treatment after the consequences of refusing care or treatment are presented. Receive appropriate care without discrimination in accordance with physician orders…BB. This Organization’s transfer and discharge policies… During a record review of the HHA’s (undated) policy and procedure titled, “Discharge Criteria and Process,” the policy indicated that a discharge summary will be completed and filed in the clinical record. The policy indicated that prior notice will not be necessary when services are discontinued by the patient or physician; however, action taken must be documented in the clinical record and a discharge summary completed. A copy of the discharge instructions will be mailed to the patient. During a record review of the HHA’s (undated) policy and procedure titled, “Discharge Summary,” the policy indicated that the discharge summary and other relevant clinical record documents will be completed within 72 hours of discharge from service.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: a. The HHA failed to assess the continuing need for home care services for two of seven sampled patients (Patient 4 and Patient 5). This deficient practice resulted in the provision of unnecessary home health services to the patients who did not need skilled nursing services. (Refer to G532). b. The HHA failed to ensure an update of the comprehensive assessments (or the Recertification assessment, the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) were completed for four of seven sampled patients (Patient 3, Patient 4, Patient 5, and Patient 6). For Patient 3 with a start of care (SOC) date of 9/13/2024, Patient 3’s clinical record did not have documented evidence an update of the comprehensive assessment was conducted and completed for the period starting from 11/12/2024 to 1/10/2025. For Patient 4 with a SOC date of 9/11/2024, Patient 4’s clinical record did not have documented evidence an update of the comprehensive assessment was conducted and completed for the period starting from 11/10/2024 to 1/8/2025. For Patient 5 with a SOC date of 9/13/2024, Patient 5’s clinical record did not have documented evidence an update of the comprehensive assessment was conducted and completed for the period starting from 11/12/2024 to 1/10/2025. For Patient 6 with a SOC date of 7/29/2024, Patient 6’s clinical record did not have documented evidence an update of the comprehensive assessment was conducted and completed for the period starting from 9/27/2024 to 11/25/2024. This failure resulted in the HHA providing care without assessing and identifying the needs of Patient 3, Patient 4, Patient 5, and Patient 6 that could potentially affect the patients’ care and services that could lead to hospitalization and death. (Refer to G546). c. The HHA failed to update the comprehensive assessment for one of seven sampled patients (Patient 6), after returning home from a hospital admission of more than 24 hours. This deficient practice had the potential to result in Patient 6’s needs not being met. (Refer to G548) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated Federal regulations for Comprehensive Assessments of Patients to ensure the highest quality health care services are provided to all certified patients receiving the benefits.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to assess the continuing need for home care services for two of seven sampled patients (Patient 4 and Patient 5). This deficient practice resulted in the provision of the unnecessary home health services to the patients who did not need skilled nursing services. Findings: a. During a review of Patient 4’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 9/11/2024, with a diagnosis that included intervertebral disc disorders (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine) with radiculopathy lumbar region (an inflammation of a nerve root in the lower back that causes pain), and polyarthritis, unspecified (a condition when five or more joints are affected by arthritis [inflammation of the joints], but the specific type of arthritis is not known). During a review of Patients 4’s Home Health Certification and Plan Of Care (POC) for the certification period starting from 9/11/2024 to 11/9/2024, the POC indicated Patient 4 was admitted to the HHA with Skilled Nurse (SN) frequency visits of twice a week for two weeks and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. The POC goal indicated Patient 4 will be free of any falls/injuries/hospitalizations, vital signs will be within normal parameters, skin integrity will remain intact, will demonstrate compliance with medication, and patient and patient caregiver will demonstrate competence in following medical regimen. The discharge planning indicated to discharge Patient 4 when goals are met, when medical condition is stable, and patient is no longer in need of skilled services. During a joint home visit, on 11/19/2024 at 3:20 p.m., at Patient 4’s residence with the registered nurse (RN 1), Patient 4 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device, and was accompanied by a family member (FM 2). During an interview with FM 2, on 11/19/2024 at 3:48 p.m., FM 2 stated Patient 4’s vital signs were within normal range, pain was controlled with medications, had no falls, no recent hospitalization, no wound treatment, performed her activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) with supervision, and went to her physician’s appointment regularly. During a concurrent interview and record review, on 11/22/2024 at 11:05 a.m., with the Director of Patient Care Services (DPCS), Patient 4’s chart and nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there were no documented evidence an updated comprehensive assessment was conducted and available for review for Patient 4, and Patient 4’s nursing visit clinical notes from 9/13/2024 to 11/17/2024 cannot be accessed and not available for review. The DPCS stated with no records available for review, she was unable to provide documented evidence Patient 4 needed skilled nursing services. DPCS stated Patient 4 was recertified for another 60 days for continuous skilled nursing services. b. During a review of Patient 5’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a review of Patients 5’s Home Health Certification and POC for the certification period starting from 9/13/2024 to 11/11/2024, the POC indicated Patient 5 was admitted to the HHA with SN frequency visits of once a week for one week, twice a week for two weeks and then once a week for six weeks for skilled observation and assessment of all body systems, perform vital signs, pain assessment using pain scale 0-10, and medication compliance and effectiveness. The POC goal indicated Patient 5 will be free of any falls/injuries/hospitalizations, vital signs will be within normal parameters, will be free from signs and symptoms of hypoglycemia (low blood sugar level)/hyperglycemia (high blood sugar level), skin integrity will remain intact, will demonstrate compliance with medication, and patient and patient caregiver will demonstrate competence in following medical regimen. The discharge planning indicated to discharge Patient 5 when goals are met, when medical condition is stable, and patient is no longer in need of skilled services. During a joint home visit, on 11/20/2024 at 9:15 a.m., at Patient 5’s residence with a licensed vocational nurse (LVN 1), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 5 stated his blood sugar was normal and well-controlled with medications, has no wounds, does not need rehabilitation services (services that help people return to daily life and live in a normal or near-normal way that includes physical therapy, occupational therapy, or speech and language therapy), has no falls, no hospitalization, goes to see his physician regularly, and still drives daily. During a concurrent interview and record review, on 11/22/2024 at 11:08 am, with the DPCS, Patient 5’s chart and nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there were no documented evidence an updated comprehensive assessment was conducted and available for review for Patient 5, and Patient 5’s nursing visit clinical notes from 9/15/2024 to 11/15/2024 cannot be accessed and not available for review. The DPCS stated with no records available for review, she was unable to provide documented evidence Patient 5 needed skilled nursing services. DPCS stated Patient 5 was recertified for another 60 days for continuous skilled nursing services. During a review of the agency’s undated policy and procedure (P&P) titled, Discharge Criteria and Process", the P&P indicated when the patient’s plan of care changes and this change results in discharge or reduction of services, the patient or his/her representative, as well as his/her primary physician, will be notified and involved in planning decisions. Services will be terminated when the patient meets one or more of the discharge criteria: if appropriate, the physician and the organization agree that the goals of home care have been attained or are no longer attainable.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure an update of the comprehensive assessments (or the recertification assessment, the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) were completed and reflected the patient’s current health status for four of seven sampled patients (Patient 3, Patient 4, Patient 5, and Patient 6). For Patient 3 with a start of care (SOC) date of 9/13/2024, Patient 3’s did not have an update of the comprehensive assessment was conducted and completed for the period starting from 11/12/2024 to 1/10/2025. For Patient 4 with a SOC date of 9/11/2024, Patient 4 did not have an updated comprehensive assessment for the period starting from 11/10/2024 to 1/8/2025. For Patient 5 with a SOC date of 9/13/2024, Patient 5’s did not have an updated of the comprehensive assessment was conducted and completed for the period starting from 11/12/2024 to 1/10/2025. For Patient 6 with a SOC date of 7/29/2024, Patient 6 did not have an updated of the comprehensive assessment was conducted and completed for the period starting from 9/27/2024 to 11/25/2024. This failure resulted in the HHA not able to provide visiting nurses to monitor Patient 3, Patient 4, Patient 5, and Patient 6 current health status that could potentially lead to hospitalization and/or death. On 11/21/2024, at 12:22 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Director of Patient Care Services (DPCS) related to the HHA failure to ensure an update of the comprehensive assessment were completed for four sampled patients (Patient 3, Patient 4, Patient 5, and Patient 6). On 11/22/2024, at 1:30 p.m., the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/22/2024, at 1:50 p.m., the survey team completed the survey tasks and conducted an exit conference, in the presence of the DPCS, Office Manager and a Volunteer, with the IJ situation not removed. On 12/26/2024 the HHA submitted the IJ removal plans and the survey team reviewed and accepted as follow: IJ removal plan for G546: 1.On 11/26/2024, the HHA completed the comprehensive assessments for Patient 3, Patient 4, Patient 5, and Patient 6. 2.On 11/26/2024, the HHA conducted a full audit of all active patient records. 3. On 11/26/2024, the HHA conducted training for all clinical staff regarding documentation. 4.On 12/17/2024, the HHA completed the comprehensive assessments for Patient 9 and Patient 13. On 12/26/2024, at 12 pm, the Department removed the IJ situation in the presence of the ADM and Volunteer after onsite verification of the HHA's IJ removal plan through observation, interview, and record review. b. During a review of Patient 4’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 9/11/2024, with a diagnosis that included intervertebral disc disorders (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine) with radiculopathy lumbar region (an inflammation of a nerve root in the lower back that causes pain), and polyarthritis, unspecified (a condition when five or more joints are affected by arthritis [inflammation of the joints], but the specific type of arthritis is not known). During a review of Patients 4’s Home Health Certification and Plan Of Care (POC) for the certification period starting from 9/11/2024 to 11/9/2024, the POC indicated Patient 4 was admitted to the HHA with Skilled Nurse (SN) frequency visits of twice a week for two weeks and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a review of Patient 4’s Nursing visit calendar, on 11/18/2024 at 3:45 p.m., the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Recertification assessment was not started and completed by the assigned nurse (RN 3) for the benefit period starting from 11/10/2024 to 1/8/2025. During a joint home visit, on 11/19/2024 at 3:20 p.m., at Patient 4’s residence with the registered nurse (RN 1), Patient 4 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device, and was accompanied by a family member (FM 2). During an interview with FM 2, on 11/19/2024 at 3:48 p.m., FM 2 stated the HHA skilled nurse visits Patient 4 at least once a week since the SOC. During a phone interview, on 11/20/2024 at 2:52 p.m. with RN 3, RN 3 stated she conducted the recertification assessment for Patient 4 in early November 2024 but has not completed and submitted her notes. RN 3 stated, “I’m behind on my notes but we were told we have 20 days to submit and upload our assessment notes in patients’ electronic records but of course, the sooner the better.” c. During a review of Patient 5’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a review of Patients 5’s Home Health Certification and POC for the certification period starting from 9/13/2024 to 11/11/2024, the POC indicated Patient 5 was admitted to the HHA with SN frequency visits of once a week for one week, twice a week for two weeks and then once a week for six weeks for skilled observation and assessment of all body systems, perform vital signs, pain assessment using pain scale 0-10, and medication compliance and effectiveness. During a review of Patient 5’s Nursing visit calendar, on 11/18/2024 at 3:55 p.m., the nursing visit calendar indicated the OASIS-E Recertification assessment was not started and completed by the assigned nurse (RN 2) for the benefit period starting from 11/12/2024 to 1/10/2025. During a joint home visit, on 11/20/2024 at 9:15 a.m., at Patient 5’s residence with a licensed vocational nurse (LVN 2), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 5 stated he has different LVN’s that comes visit him at least once a week since the SOC but cannot recall the exact date the last time he was visited by RN 2. During a phone interview, on 11/21/2024 at 10:00 a.m. with RN 2, RN 2 stated he was never notified by the HHA and did not visit and did not conduct the recertification assessment for Patient 5. During a concurrent interview and record review, on 11/21/2024 at 11:12 am, with the DPCS, Patient 4 and Patient 5’s Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there were no documented evidence an updated comprehensive assessment was conducted for Patient 4 for the benefit period starting on 11/10/2024 to 1/8/2025 and for Patient 5 for the benefit period starting on 11/12/2024 to 1/10/2025. The DPCS stated a recertification assessment including OASIS items should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period. The DPCS further stated it was important to complete the nursing comprehensive assessment timely in order for the HHA to generate the patient’s plan of care so that skilled nurses will know how to care for the patient. d. During a review of Patient 6’s Face Sheet, the Face Sheet indicated a SOC date of 7/29/2024, with a diagnosis that includes bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, and radiculopathy lumbar region. During a review of Patients 6’s Home Health Certification and POC for the certification period starting from 7/29/2024 to 9/26/2024, the POC indicated Patient 6 was admitted to the HHA with SN frequency visits of twice a week for two weeks, and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs, pain assessment using pain scale 0-10, and medication compliance and effectiveness. During a concurrent interview and record review, on 11/18/2024 at 3:20 pm, with the DPCS, Patient 6’s Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 6 for the new period starting on 9/27/2024 to 11/25/2024. The DPCS stated a follow-up comprehensive nursing assessment including OASIS items should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period of home health services. During a review of the agency's undated policy and procedure (P&P) titled, Reassessment/Recertification, the P&P indicated the comprehensive assessment must be updated and revised every 60 days beginning with the start of care. A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress towards outcomes. OASIS assessments for recertification, significant change in condition, transfer, resumption of care and discharge will be completed within the mandated time frames. For each new episode of care, a comprehensive assessment will be completed no earlier than five days before and no later than one day before the calendar day on which the new episode of care will begin. Findings: a. During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis of Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a review of Patients 3’s Home Health Certification and Plan Of Care (POC) for the certification period starting from 9/13/2024 to 11/11/2024, the POC indicated Patient 3 was admitted to the HHA with Skilled Nurse (SN) frequency visits of once a week for one week, twice a week for two weeks, and once a week for 6 weeks to perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), skilled observation and assessment of all body systems, and medication compliance and effectiveness. During a record review of Patient 3’s Nursing visit calendar, the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Recertification assessment (an update to the comprehensive assessment) was not started and completed by the assigned nurse (RN3) for the benefit period starting from 11/12/2024 to 1/10/2025. During an interview on11/20/2024 at 11:03 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated that the assigned nurse should complete the recertification assessment of the patient five days prior to the start of care of the next certification period. During an interview on 11/21/2024 at 12:04 p.m., RN3 stated that she did not complete Patient 3’s assessment and would complete it today. RN3 stated she was behind in her notes and was catching up.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to update the comprehensive assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) for one of seven sampled patients, (Patient 6) after returning home from a hospital admission of more than 24 hours. This deficient practice had the potential to result in Patient 6’s identified needs not being met. Findings: During a review of Patient 6’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 7/29/2024, with a diagnosis that includes bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, and radiculopathy lumbar region (an inflammation of a nerve root in the lower back that causes pain). During a review of Patients 6’s Home Health Certification and Plan of Care (POC) for the certification period starting from 7/29/2024 to 9/26/2024, the POC indicated Patient 6 was admitted to the HHA with skilled nurse (SN) frequency visits of twice a week for two weeks, and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a concurrent interview and record review, on 11/18/2024 at 3:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 6’s Nursing visit calendar. The DPCS stated Patient 6 was admitted to acute hospital on 9/17/2024 and was discharged home on 9/21/2024. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted and completed for Patient 6 after returning home from a hospital admission on 9/21/2024. The DPCS stated, “We must do resumption of care assessment within 48 hours when patients return from the hospital for 24 hours or more of hospital admission. For Patient 6, the resumption of care was not done.” During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, the P&P indicated a comprehensive patient assessment will be completed within five calendar days of the patient’s start of care. This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter: 1. The last five days of every 60-day episode beginning with the start of care date (recertification) 2. Upon transfer 3. Significant change in condition resulting in a new case mix 4. Within 48 hours of the patient’s return home or of this Organization’s knowledge of the patient’s return from a 24-hour hospital admission for other than diagnostic testing, or on the physician-ordered resumption date 5. At discharge

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation for Care Planning, Coordination, Quality of Care was met as follows: The HHA failed to develop and implement a plan of care (POC) for five of seven patients (Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) based on identified initial and updated assessments. For Patient 2 with a start of care (SOC) of 11/4/2024, not being monitored for signs and symptoms of hypoglycemia (high blood sugar) or hyperglycemia (high blood sugar) and high blood pressure that could lead to serious harm, hospitalization and/or death. For Patient 3 with a start of care (SOC) date of 9/13/2024, not being monitored for signs and symptoms of hypoglycemia or hyperglycemia that could lead to serious harm, hospitalization and/or death. For Patient 4 with a SOC date of 9/11/2024, had the potential to experience undetected serious complications due to high blood pressure that could lead to serious harm, hospitalization and/or death. For Patient 5 with a SOC date of 9/13/2024, not being monitored for signs and symptoms of hypoglycemia or hyperglycemia that could lead to serious harm, hospitalization and/or death. For Patient 6 with a SOC date of 7/29/2024, not being monitored for signs and symptoms related to complications from dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) and that could lead to serious harm, hospitalization and/or death. This failure resulted in the Patient 2, Patient 3, and Patient 5, had potential to experience complication from hypoglycemia and hyperglycemia. For Patient 2 and Patient 4, had the potential to experience unmonitored high blood pressure. For Patient 6, had the potential to experience unmonitored complication from dialysis. These failures could lead to Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 delayed care, hospitalization and death. (Refer to G572) The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

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 observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop and implement a plan of care (POC) for five of seven patients (Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) based on identified initial and updated assessments. For Patient 2 with a start of care (SOC) of 11/4/2024, not being monitored for signs and symptoms of hypoglycemia (high blood sugar) or hyperglycemia (high blood sugar) and high blood pressure that could lead to serious harm, hospitalization and/or death. For Patient 3 with a start of care (SOC) date of 9/13/2024, not being monitored for signs and symptoms of hypoglycemia or hyperglycemia that could lead to serious harm, hospitalization and/or death. For Patient 4 with a SOC date of 9/11/2024, had the potential to experience undetected serious complications due to high blood pressure that could lead to serious harm, hospitalization and/or death. For Patient 5 with a SOC date of 9/13/2024, not being monitored for signs and symptoms of hypoglycemia or hyperglycemia that could lead to serious harm, hospitalization and/or death. For Patient 6 with a SOC date of 7/29/2024, not being monitored for signs and symptoms related to complications from dialysis and that could lead to serious harm, hospitalization and/or death. This failure resulted in the Patient 2, Patient 3, and Patient 5, had potential to experience complication from hypoglycemia and hyperglycemia. For Patient 4, had the potential to experience unmonitored high blood pressure. For Patient 6, had the potential to experience unmonitored complication from dialysis, could lead to Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 delayed care, hospitalization and death. On 11/21/2024 at 12:33 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency's Director of Patient Care Services (DPCS), related to the of the HHA’s failure to ensure a plan of care (POC) was developed and implemented for five of seven patients (Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). On 11/22/2024 at 1:50 p.m., the survey team conducted an exit conference in the presence of the DPCS, Office Manager, and a volunteer, with the IJ not removed. IJ removal plan for G572: 1.On 11/26/2024, the HHA completed the plan of care for Patient 2, Patient 3, Patient 5, and Patient 6 to reflect their current health status, needs, and goals of care. 2.On 11/26/2024, the HHA audited 108 records and identified that eleven patients had incomplete plan of care and updated the plan of care. 3. On 11/26/2024, the HHA conducted training for all clinical staff regarding documentation. 4.On 12/17/2024, the HHA developed and updated the plan of care for Patient 9 and Patient 13. On 12/26/2024, at 12:03 pm, the Department removed the IJ situation in the presence of the ADM and Volunteer after onsite verification of the HHA's IJ removal plan through observation, interview, and record review. c. During a review of Patient 4’s Face Sheet, the Face Sheet indicated a SOC date of 9/11/2024, with a diagnosis that includes intervertebral disc disorders (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine) with radiculopathy lumbar region (an inflammation of a nerve root in the lower back that causes pain), and polyarthritis, unspecified (a condition when five or more joints are affected by arthritis [inflammation of the joints], but the specific type of arthritis is not known). During a review of Patient 4’s electronic charting (E-chart) software (Kinnser), on 11/18/2024 at 3:46 p.m., Patient 4’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/10/2024 to 1/8/2025. During a joint home visit, on 11/19/2024 at 3:20 p.m., at Patient 4’s residence with the registered nurse (RN 1), Patient 4 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device, and was accompanied by a family member (FM 2). During an interview with FM 2, on 11/19/2024 at 3:48 p.m., FM 2 stated the HHA skilled nurse visits Patient 4 at least once a week since the SOC. During a phone interview, on 11/20/2024 at 2:52 p.m. with RN 3, RN 3 stated she conducted the recertification assessment for Patient 4 in early November 2024 but has not completed and submitted her notes. RN 3 stated, “I’m behind on my notes but we were told we have 20 days to submit and upload our assessment notes in patients’ electronic records but of course, the sooner the better.” RN 3 further stated Patient 4’s plan of care will be generated and forwarded to the patient’s physician for signature once she completed her comprehensive assessment. d. During a review of Patient 5’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis that includes type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a review of Patient 5’s E-chart, on 11/18/2024 at 3:57 p.m., Patient 5’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/12/2024 to 1/10/2025. During a joint home visit, on 11/20/2024 at 9:15 a.m., at Patient 5’s residence with a licensed vocational nurse (LVN 2), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 5 stated he has different LVN’s that comes visit him at least once a week since the SOC. During a concurrent interview and record review, on 11/21/2024 at 11:12 am, with the DPCS, Patient 4 and Patient 5’s E-chart Orders and Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 4 for the new period starting on 11/10/2024 to 1/8/2025 and has no current plan of care. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 5 for the new period starting on 11/12/2025 to 1/10/2025 and has no current plan of care. The DPCS stated a recertification nursing assessment should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period. The DPCS stated it was important to complete the nursing comprehensive assessment timely in order for the HHA to generate the patient’s plan of care so that skilled nurses know how to care for the patient. The DPCS stated, “If we don’t have patient’s plan of care, we don’t know how to care for the patient, which has a potential for harm in failure to properly care for the patient.” e. During a review of Patient 6’s Face Sheet, the Face Sheet indicated a SOC date of 7/29/2024, with a diagnosis that includes bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, and radiculopathy lumbar region. During a concurrent interview and record review, on 11/18/2024 at 3:20 pm, with the DPCS, Patient 6’s E-chart Orders and Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 6 for the period starting from 9/27/2024 to 11/25/2024 and has no current plan of care. The DPCS stated a follow-up comprehensive nursing assessment should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period of home health services and the patient's plan of care should have been generated within seven days after the assessment. During a review of the agency's undated policy and procedure (P&P) titled, Care Planning Process, the P&P indicated a written plan of care will be initiated within 5 days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient plan of care will be developed or revised within five working days of initiation or of the reassessment of the patient. All clinicians involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Findings: a. During a record review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a Start of Care (SOC) date on 11/04/2024. The facesheet indicated a current episode of 11/04/2024 to 1/2/2025 and the primary diagnosis was blank. During a review of Patient 2’s Nursing Visit Calendar, the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Start of Care was saved by Registered Nurse (RN2). During a record review of Patient 2’s Orders for the certification period starting from 11/4/2024 to 1/2/2025, the Orders indicated there were no plan of care completed. During a record review of Patient 2’s Patient Referral and Orders, dated 11/3/2024, the referral indicated for an order for home health services, skilled nurse to follow up with patient with home safety, monitoring condition and adherence with medication and management, and monitoring vital signs and overall wellness. The referral indicated to teach about medication compliance and management. The referral indicated a diagnosis of hypertension (high blood pressure), hyperlipidemia (high cholesterol), diabetes type II (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), fatigue and weakness. The referral indicated that Patient 2 presented with unstable blood pressure, fatigue, unstable blood sugar and generalized weakness. During an interview and record review on 11/18/2024 at 2 p.m., with the Director of Patient Care (DPCS), Patient 2’s Orders were reviewed. The DPCS stated that there was no Plan of Care in the chart because it was not completed. During a joint home visit on 11/19/2024 at 1:30 p.m., with Licensed Vocational Nurse (LVN1), Patient 2 was visited at his residence. When LVN1 was asked what was supposed to be done during Patient 2’s visit, LVN1 stated she normally takes the patients vital signs and does a head to toe assessment. LVN1 checked the Patient’s HHA binder and there was no plan of care located. LVN1 was observed taking Patient 2’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). When asked how often he checked his blood sugar, Patient 2 stated he checks his blood sugar every two weeks. Patient 2 checked his blood sugar using a lancet device (device that holds a small needle to make a tiny prick on skin to obtain a drop of blood) and glucometer (device to measure blood sugar). Patient 2 stated that his blood sugar was 134 and asked, “Is that good or bad?” and the LVN1 stated it was good. Patient 2 stated that he was on 500 milligrams (mg, a unit of measurement) of metformin a day because he was prediabetic. Patient 2 attempted to remove the needle from the lancet device, but then stated he did not know how to take the needle out. LVN1 took the lancet device and removed the needle and disposed it in a sharp’s container. During an interview on 11/19/2024 at 2:22 p.m., LVN1 stated that the HHA only provided her Patient 2’s facesheet and did not provide her with a plan of care or a medication profile. b. During a review of Patient 3’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. During a record review of Patient 3’s Orders for the certification period starting from 11/12/2024 to 1/10/2025, the Orders indicated there was no plan of care completed. During an interview on 11/20/2024 at 11:03 a.m., the Director of Patient Care Services (DPCS) stated that a Plan of Care was required so the LVN knows what home health services to provide for the patient. The DPCS stated that the Plan of Care should be done within seven days of the start of care. During an interview on 11/21/2024 at 12:19 p.m., when asked why it was important for Patient 2 and Patient 3 to have a plan of care, the DPCS stated that a plan of care is important because it tells the nurse what medications, orders, and treatments are prescribed by the doctor and what to do during the home visit. During a record review of the HHA’s (undated) policy titled “Care Planning Process,” the policy indicated that a written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days or as patient's condition warrants. The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. All clinicians involved in the patient's care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation for Organization and Administration of services as follows: The HHA failed to ensure the governing body and administrator, assumed full responsibility for the day-to-day operation of the home health services, and failed to ensure continuous, patients’ health assessment and quality patient care and services were provided to five of seven sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This deficient practice resulted in Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 did not have a completed comprehensive assessment and developed a plan of care which had the potential to result in affecting the provision of quality care to the patients under home health services. Refer to G 942. The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulations for Organization and administration of services to ensure highest quality health care was provided to patients assessed to receive home health services.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the governing body and administrator, assumed full responsibility for the day-to-day operation of the home health services, and failed to ensure continuous, patients’ health assessment and quality patient care and services were provided to five of seven sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This deficient practice resulted in Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 did not have a completed comprehensive assessment and developed a plan of care which had the potential to result in affecting the provision of quality care to the patients under home health services. Findings: During an interview on 11/18/2024, at 12:30 p.m., with the Office manager (OM), the OM stated she did not know who the agency’s Administrator was but will ask the owner. During an interview on 11/18/2024, at 12:40 p.m., with the Director of Patient Care Services (DPCS), the DPCS was asked who the agency’s Administrator was. The DPCS stated, “Maybe I am too. I just started working here.” a. During a record review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a Start of Care (SOC) date on 11/04/2024. The Face Sheet indicated the current episode of 11/04/2024 to 1/2/2025 and the entry for the primary diagnosis was not filled out. During a record review of Patient 2’s Nursing Visit Calendar, the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Start of Care was saved by Registered Nurse (RN2) and when reviewed, was not filled out completely including the section for vitals, patient history and prognosis, active diagnosis, health conditions, medication, and orders for discipline and treatments. During an interview and record review on 11/18/2024 at 2 p.m., with the DPCS, Patient 2’s orders were reviewed by the DPCS. The DPCS stated that there was no Plan of Care in the chart because it was not completed. b. During a record review of Patient 3’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis of Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a record review of Patient 3’s Nursing visit calendar, the nursing visit calendar indicated the OASIS-E Recertification assessment (an update to the comprehensive assessment) was not started and completed by the assigned nurse (RN3) for the benefit period starting from 11/12/2024 to 1/10/2025. During a record review of Patient 3’s Orders for the certification period starting from 11/12/2024 to 1/10/2025, the Orders indicated there was no plan of care completed. c. During a review of Patient 4’s Face Sheet, the Face Sheet indicated a SOC date of 9/11/2024, with a diagnosis that includes intervertebral disc disorders (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine) with radiculopathy lumbar region (an inflammation of a nerve root in the lower back that causes pain), and polyarthritis, unspecified (a condition when five or more joints are affected by arthritis [inflammation of the joints], but the specific type of arthritis is not known). During a review of Patient 4’s Nursing visit calendar, on 11/18/2024 at 3:45 p.m., the nursing visit calendar indicated the OASIS-E Recertification assessment was not started and completed by the assigned nurse (RN 3) for the benefit period starting from 11/10/2024 to 1/8/2025, and there were no nursing visit clinical notes accessible and available for review starting from 9/13/2024 to 11/17/2024. During a review of Patient 4’s electronic charting (E-chart) software (Kinnser), on 11/18/2024 at 3:46 p.m., Patient 4’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/10/2024 to 1/8/2025. d. During a review of Patient 5’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis that includes type 2 diabetes mellitus with hyperglycemia. During a review of Patient 5’s Nursing visit calendar, on 11/18/2024 at 3:55 p.m., the nursing visit calendar indicated the OASIS-E Recertification assessment was not started and completed by the assigned nurse (RN 2) for the benefit period starting from 11/12/2024 to 1/10/2025, and there were no nursing visit clinical notes that was accessible and available for review starting from 9/15/2024 to 11/15/2024. During a review of Patient 5’s E-chart, on 11/18/2024 at 3:57 p.m., Patient 5’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/12/2024 to 1/10/2025. e. During a review of Patient 6’s Face Sheet, the Face Sheet indicated a SOC date of 7/29/2024, with a diagnosis that includes bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, and radiculopathy lumbar region. During a concurrent interview and record review, on 11/18/2024 at 3:20 pm, with the DPCS, Patient 6’s E-chart Orders and Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 6 for the period starting from 9/27/2024 to 11/25/2024, had no current plan of care, and Patient 6’s nursing visit clinical notes from 8/9/2024 to 10/23/2024 were not available for review. During an interview on 11/20/2024 at 11:03 a.m., with the DPCS, the DPCS stated that the assigned nurse should complete the recertification assessment of the patient five days prior to the start of care of the next certification period. During an interview on 11/21/2024 at 12:19 p.m., the DPCS stated that a plan of care was important because it tells the nurse what medications, orders, and treatments were prescribed by the doctor. During a concurrent interview and record review, on 11/22/2024 at 12:12 p.m. with the DPCS, the HHA's "Governing Body Minutes" binder was reviewed by the DPCS. The DPCS stated and acknowledged there were no Governing Body meetings conducted for the year 2023 and 2024. The DPCS further stated the Performance Improvement program and the QAPI plans section of the Governing Body minutes binder were empty. During a review of the agency’s undated policy and procedure (P&P) titled, Governing Body, the P&P indicated the Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resource management, review of this organization’s budget and operational plans, and its quality assessment and performance improvement (QAPI) program. During a review of the agency’s undated P&P titled, Admission Criteria and Process”, the P&P indicated once a patient is admitted to service, this Organization is responsible for providing care and services within its financial and service capabilities, mission, and applicable law and regulations.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation for Clinical Records were met as follows: a. The HHA failed to ensure the patient’s clinical records, including an updated comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services), the plan of care (documents the process of identifying a patient's needs and facilitating holistic care (treatment of the whole person, taking account the mental and social factors, not just the symptoms of the illness) and ensures collaboration among nurses, patients, and other healthcare providers), and nursing visit clinical notes were completed, accessible, and available for review for six out of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This failure had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 in not receiving appropriate care and services necessary to maintain the highest practicable (highest level of function and well-being) mental, medical, and physical well-being under the agency’s care that could lead to patient’s hospitalization and death. (Refer to G1012). 2. The HHA failed to ensure the patient’s discharge summary was completed and filed in the clinical record for one of seven sampled patients (Patient 1). This failure resulted in Patient 1 unable to receive physical therapy services after the patient requested to be discharged from home health services. (Refer to G1022) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with the Federal regulations for Clinical Records to ensure patients' clinical records are complete, accurate, containing the past and current information for continuity of care, and coordination among the HHA staff providing the highest quality of care and services to these certified patients receiving the home health benefits.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the patient’s clinical records, including an updated comprehensive assessment (or the Recertification assessment, the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services), the plan of care (documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers), and nursing visit clinical notes were completed, accessible, and available for review for six out of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This failure had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 in not receiving appropriate care and services necessary to maintain the highest practicable (highest level of function and well-being) mental, medical, and physical well-being under the agency’s care that could lead to patient’s hospitalization and death. On 11/21/2024, at 12:45 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Director of Patient Care Services (DPCS) related to the HHA failure to provide an updated comprehensive assessment, the current plan of care, and nursing visit clinical notes for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6. As a result, the non-compliance resulted in incomplete clinical records that does not reflect patients' current condition and needs which likely to cause unidentified needs, serious injury, harm, impairment, or death to a patient. On 11/22/2024, at 1:30 p.m., the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/22/2024, at 1:50 p.m., the survey team completed the survey tasks and conducted an exit conference, in the presence of the DPCS, Office manager and a volunteer, with the IJ situation not removed. IJ removal plan for G1012: 1.On 11/26/2024, the HHA completed the comprehensive assessments, plan of care, and missing nursing visit clinical notes for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6. 2.On 11/26/2024, the HHA completed an audit of 108 records and identified that nine patients had incomplete comprehensive assessments. 3. On 11/26/2024, the HHA identified 88 patients had incomplete visit notes and completed the visit notes. 4. On 11/26/2024, the HHA conducted training for all clinical staff regarding documentation. 5.On 12/17/2024, the HHA identified 71 patients with incomplete comprehensive assessments and completed the assessments. On 12/26/2024, at 12:05 pm, the Department removed the IJ situation in the presence of the ADM and Volunteer after onsite verification of the HHA's IJ removal plan through observation, interview, and record review. a. During a record review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 8/8/2024, with a diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patients ’s Home Health Certification and Plan Of Care (POC) for the certification period starting from 10/7/2024 to 12/05/2024, the POC indicated Patient 1 was admitted to the HHA with Skilled Nurse (SN) frequency visits of twice a week for two weeks and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a record review of Patient 1 Nursing visit calendar, the nursing visit calendar indicated that from 8/13/2024 to 10/7/2024 was completed, but was not accessible and available for review. b. During a record review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a Start of Care (SOC) date on 11/04/2024. The facesheet indicated a current episode of 11/04/2024 to 1/2/2025 and the primary diagnosis was blank. During a record review of Patient 2’s Nursing Visit Calendar, the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Start of Care was saved by Registered Nurse (RN2) and when reviewed, was blank and not completed. During a record review of Patient 2’s Patient Referral and Orders, dated 11/3/2024, the referral indicated for an order for home health services, skilled nurse to follow up with patient with home safety, monitoring condition and adherence with medication and management, and monitoring vital signs and overall wellness. The referral indicated to teach about medication compliance and management. The referral indicated a diagnosis of hypertension (high blood pressure), hyperlipidemia (high cholesterol), diabetes type II (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), fatigue and weakness. The referral indicated that Patient 2 presented with unstable blood pressure, fatigue, unstable blood sugar and generalized weakness. During an interview and record review on 11/18/2024 at 2 p.m., with the Director of Patient Care (DPCS), Patient 2’s Orders were reviewed. The DPCS stated that there was no Plan of Care in the chart because it was not completed. During a joint home visit on 11/19/2024 at 1:30 p.m., with Licensed Vocational Nurse (LVN1), Patient 2 was visited at his residence. When LVN1 was asked what was supposed to be done during Patient 2’s visit, LVN1 stated she normally takes the patients vital signs and does a head to toe assessment. LVN1 checked the Patient’s HHA binder and there was no plan of care located. LVN1 was observed taking Patient 2’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). During an interview and record review on 11/21/2024 at 11:30 a.m., with the DPCS, Patient 2’s Nursing visit calendar was reviewed and indicated skilled nursing visits for dates 11/5/2024, 11/8/2024, and 11/12/2024 and 11/15/2024 were not started. DPCS stated that Patient 2 was not visited on 11/5/2024, 11/12/2024 or 11/15/2024. The DPCS stated Patient 2 was visited on 11/8/2024 and that there were no notes entered for this day. During a telephone interview on 11/21/2024 at 11:34 a.m., the Registered Nurse (RN2) stated he performed Patient 2’s initial assessment, documented his assessment, and submitted it to the HHA office. RN2 stated he did not upload the assessment into Patient 2’s electronic chart. c. During a record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis of Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a record review of Patients 3’s Home Health Certification and Plan Of Care (POC) for the certification period starting from 9/13/2024 to 11/11/2024, the POC indicated Patient 3 was admitted to the HHA with Skilled Nurse (SN) frequency visits of once a week for one week, twice a week for two weeks, and once a week for 6 weeks to perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), skilled observation and assessment of all body systems, and medication compliance and effectiveness. During a record review of Patient 3’s Nursing visit calendar, the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Recertification assessment (an update to the comprehensive assessment) was not started and completed by the assigned nurse (RN3) for the benefit period starting from 11/12/2024 to 1/10/2025. During a record review of Patient 3’s Orders for the certification period starting from 11/12/2024 to 1/10/2025, the Orders indicated there was no plan of care completed. During an interview on11/20/2024 at 11:03 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated that the assigned nurse should complete the recertification assessment of the patient five days prior to the start of care of the next certification period. During an interview on 11/21/2024 at 12:04 p.m., RN3 stated that she did not complete Patient 3’s assessment and would complete it today. RN3 stated she was behind in her notes and was catching up. During an interview on 11/21/2024 at 12:19 p.m., the DPCS stated that a plan of care is important because it tells the nurse what medications, orders, and treatments are prescribed by the doctor. d. During a review of Patient 4’s Face Sheet, the Face Sheet indicated a SOC date of 9/11/2024, with a diagnosis that includes intervertebral disc disorders (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine) with radiculopathy lumbar region (an inflammation of a nerve root in the lower back that causes pain), and polyarthritis, unspecified (a condition when five or more joints are affected by arthritis [inflammation of the joints], but the specific type of arthritis is not known). During a review of Patient 4’s Nursing visit calendar, on 11/18/2024 at 3:45 p.m., the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Recertification assessment was not started and completed by the assigned nurse (RN 3) for the benefit period starting from 11/10/2024 to 1/8/2025, and there was no nursing visit clinical notes accessible and available for review starting from 9/13/2024 to 11/17/2024. During a review of Patient 4’s electronic charting (E-chart) software (Kinnser), on 11/18/2024 at 3:46 p.m., Patient 4’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/10/2024 to 1/8/2025. During a joint home visit, on 11/19/2024 at 3:20 p.m., at Patient 4’s residence with the registered nurse (RN 1), Patient 4 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device, and was accompanied by a family member (FM 2). During an interview with FM 2, on 11/19/2024 at 3:48 p.m., FM 2 stated the HHA skilled nurse visits Patient 4 at least once a week since the SOC. During a phone interview, on 11/20/2024 at 2:52 p.m. with RN 3, RN 3 stated she conducted the recertification assessment for Patient 4 in early November 2024 but has not completed and submitted her notes. RN 3 stated, “I’m behind on my notes but we were told we have 20 days to submit and upload our assessment notes in patients’ electronic records but of course, the sooner the better.” RN 3 further stated Patient 4’s plan of care will be generated and forwarded to the patient’s physician for signature once she completed her comprehensive assessment. e. During a review of Patient 5’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis that includes type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a review of Patient 5’s Nursing visit calendar, on 11/18/2024 at 3:55 p.m., the nursing visit calendar indicated the OASIS-E Recertification assessment was not started and completed by the assigned nurse (RN 2) for the benefit period starting from 11/12/2024 to 1/10/2025, and there was no nursing visit clinical notes that was accessible and available for review starting from 9/15/2024 to 11/15/2024. During a review of Patient 5’s E-chart, on 11/18/2024 at 3:57 p.m., Patient 5’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/12/2024 to 1/10/2025. During a joint home visit, on 11/20/2024 at 9:15 a.m., at Patient 5’s residence with a licensed vocational nurse (LVN 2), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 5 stated he has different LVN’s that comes visit him at least once a week since the SOC but cannot recall the exact date the last time he was visited by RN 2. During a phone interview, on 11/21/2024 at 10:00 a.m. with RN 2, RN 2 stated he was never notified by the HHA and did not visit and did not conduct a recertification assessment for Patient 5. During a concurrent interview and record review, on 11/21/2024 at 11:12 am, with the DPCS, Patient 4 and Patient 5’s E-chart Orders and Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 4 for the new period starting on 11/10/2024 to 1/8/2025, has no current plan of care, and Patient 4’s nursing visit clinical notes from 9/13/2024 to 11/17/2024 cannot be accessed and therefore not available for review. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 5 for the new period starting on 11/12/2025 to 1/10/2025, has no current plan of care, and Patient 5’s nursing visit clinical notes from 9/15/2024 to 11/15/2024 cannot be accessed and not available for review. The DPCS stated a recertification assessment including OASIS items should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period. The DPCS stated it was important to complete the nursing comprehensive assessment timely in order for the HHA to generate the patient’s plan of care so that skilled nurses know how to care for the patient. The DPCS stated, “If we don’t have patient’s plan of care, we don’t know how to care for the patient, which has a potential for harm in the failure to properly care for the patient.” The DPCS further stated nursing visit notes should have been submitted within 24 to 48 hours after the service was rendered per the agency’s policies. f. During a review of Patient 6’s Face Sheet, the Face Sheet indicated a SOC date of 7/29/2024, with a diagnosis that includes bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, and radiculopathy lumbar region. During a concurrent interview and record review, on 11/18/2024 at 3:20 pm, with the DPCS, Patient 6’s E-chart Orders and Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 6 for the period starting from 9/27/2024 to 11/25/2024, has no current plan of care, and Patient 6’s nursing visit clinical notes from 8/9/2024 to 10/23/2024 were not available for review. The DPCS stated she does not know why nurses’ visit notes cannot be accessed and are not available for review but will call the visiting nurses to find out. The DPCS stated a follow-up comprehensive nursing assessment should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period of home health services, and nursing visit notes should be submitted within 24-48 hours after the visit was conducted. During a review of the agency's undated policy and procedure (P&P) titled, Clinical/Service Data Collection, the P&P indicated home care personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. During a review of the agency’s P&P titled, Contents of the Clinical Records, the P&P indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. During a review of the agency's undated P&P titled, Reassessment/Recertification, the P&P indicated the comprehensive assessment must be updated and revised every 60 days beginning with the start of care. A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress towards outcomes. OASIS assessments for recertification, significant change in condition, transfer, resumption of care and discharge will be completed within the mandated time frames. For each new episode of care, a comprehensive assessment will be completed no earlier than five days before and no later than one day before the calendar day on which the new episode of care will begin. During a review of the agency's undated P&P titled, Care Planning Process, the P&P indicated a written plan of care will be initiated within 5 days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient plan of care will be developed or revised within five working days of initiation or of the reassessment of the patient. All clinicians involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Finding: a. During a record review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/8/2024, with a diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patients ’s Home Health Certification and Plan Of Care (POC) for the certification period starting from 10/7/2024 to 12/05/2024, the POC indicated Patient 1 was admitted to the HHA with Skilled Nurse (SN) frequency visits of twice a week for two weeks and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a record review of Patient 1 Nursing visit calendar, the nursing visit calendar indicated that from 8/13/2024 to 10/7/2024 was completed, however, these visit notes were not accessible and available for review. b. During a record review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a Start of Care (SOC) date on 11/04/2024. The Face Sheet indicated a current episode of 11/04/2024 to 1/2/2025 and the entry for the primary diagnosis was not filled out. During a record review of Patient 2’s Nursing Visit Calendar, the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Start of Care was saved by Registered Nurse (RN2) and when reviewed, was not filled out completely including the section for vitals, patient history and prognosis, active diagnosis, health conditions, medication , and orders for discipline and treatments. During a record review of Patient 2’s Patient Referral and Orders, dated 11/3/2024, the referral indicated for an order for home health services, skilled nurse to follow up with patient with home safety, monitoring condition and adherence with medication and management, and monitoring vital signs and overall wellness. The referral indicated to teach about medication compliance and management. The referral indicated a diagnosis of hypertension (high blood pressure), hyperlipidemia (high cholesterol), diabetes type II (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), fatigue and weakness. The referral indicated that Patient 2 presented with unstable blood pressure, fatigue, unstable blood sugar and generalized weakness. During an interview and record review on 11/18/2024 at 2 p.m., with the Director of Patient Care (DPCS), Patient 2’s Orders were reviewed. The DPCS stated that there was no Plan of Care in the chart because it was not completed. During a joint home visit on 11/19/2024 at 1:30 p.m., with Licensed Vocational Nurse (LVN1), Patient 2 was visited at his residence. When LVN1 was asked what was supposed to be done during Patient 2’s visit, LVN1 stated she normally takes the patients vital signs and does a head to toe assessment. LVN1 checked the Patient’s HHA binder and there was no plan of care located. LVN1 was observed taking Patient 2’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). During an interview and record review on 11/21/2024 at 11:30 a.m., with the DPCS, Patient 2’s Nursing visit calendar was reviewed and indicated skilled nursing visits for dates 11/5/2024, 11/8/2024, and 11/12/2024 and 11/15/2024 were not started. DPCS stated that Patient 2 was not visited on 11/5/2024, 11/12/2024 or 11/15/2024. The DPCS stated Patient 2 was visited on 11/8/2024 and that there were no notes entered for this day. During a telephone interview on 11/21/2024 at 11:34 a.m., the Registered Nurse (RN2) stated he performed Patient 2’s initial assessment, documented his assessment, and submitted it to the HHA office. RN2 stated he did not upload the assessment into Patient 2’s electronic chart. c. During a record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis of Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a record review of Patients 3’s Home Health Certification and Plan Of Care (POC) for the certification period starting from 9/13/2024 to 11/11/2024, the POC indicated Patient 3 was admitted to the HHA with Skilled Nurse (SN) frequency visits of once a week for one week, twice a week for two weeks, and once a week for 6 weeks to perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), skilled observation and assessment of all body systems, and medication compliance and effectiveness. During a record review of Patient 3’s Nursing visit calendar, the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Recertification assessment (an update to the comprehensive assessment) was not started and completed by the assigned nurse (RN3) for the benefit period starting from 11/12/2024 to 1/10/2025. During a record review of Patient 3’s Orders for the certification period starting from 11/12/2024 to 1/10/2025, the Orders indicated there was no plan of care completed. During an interview on11/20/2024 at 11:03 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated that the assigned nurse should complete the recertification assessment of the patient five days prior to the start of care of the next certification period. During an interview on 11/21/2024 at 12:04 p.m., RN3 stated that she did not complete Patient 3’s assessment and would complete it today. RN3 stated she was behind in her notes and was catching up. During an interview on 11/21/2024 at 12:19 p.m., the DPCS stated that a plan of care is important because it tells the nurse what medications, orders, and treatments are prescribed by the doctor. d. During a review of Patient 4’s Face Sheet, the Face Sheet indicated a SOC date of 9/11/2024, with a diagnosis that includes intervertebral disc disorders (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine) with radiculopathy lumbar region (an inflammation of a nerve root in the lower back that causes pain), and polyarthritis, unspecified (a condition when five or more joints are affected by arthritis [inflammation of the joints], but the specific type of arthritis is not known). During a review of Patient 4’s Nursing visit calendar, on 11/18/2024 at 3:45 p.m., the nursing visit calendar indicated the OASIS-E (or the Outcome and Assessment Information Set, is an extensive assessment tool that gathers data related to a home health patient’s general information, current condition and services needed) Recertification assessment was not started and completed by the assigned nurse (RN 3) for the benefit period starting from 11/10/2024 to 1/8/2025, and there was no nursing visit clinical notes accessible and available for review starting from 9/13/2024 to 11/17/2024. During a review of Patient 4’s electronic charting (E-chart) software (Kinnser), on 11/18/2024 at 3:46 p.m., Patient 4’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/10/2024 to 1/8/2025. During a joint home visit, on 11/19/2024 at 3:20 p.m., at Patient 4’s residence with the registered nurse (RN 1), Patient 4 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device, and was accompanied by a family member (FM 2). During an interview with FM 2, on 11/19/2024 at 3:48 p.m., FM 2 stated the HHA skilled nurse visits Patient 4 at least once a week since the SOC. During a telephone interview, on 11/20/2024 at 2:52 p.m. with RN 3, RN 3 stated she conducted the recertification assessment for Patient 4 in early November 2024 but has not completed and submitted her notes. RN 3 stated, “I’m behind on my notes but we were told we have 20 days to submit and upload our assessment notes in patients’ electronic records but of course, the sooner the better.” RN 3 further stated Patient 4’s plan of care will be generated and forwarded to the patient’s physician for signature once she completed her comprehensive assessment. e. During a review of Patient 5’s Face Sheet, the Face Sheet indicated a SOC date of 9/13/2024, with a diagnosis that includes type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a review of Patient 5’s Nursing visit calendar, on 11/18/2024 at 3:55 p.m., the nursing visit calendar indicated the OASIS-E Recertification assessment was not started and completed by the assigned nurse (RN 2) for the benefit period starting from 11/12/2024 to 1/10/2025, and there was no nursing visit clinical notes that was accessible and available for review starting from 9/15/2024 to 11/15/2024. During a review of Patient 5’s E-chart, on 11/18/2024 at 3:57 p.m., Patient 5’s E-chart indicated that under the section “Orders”, there was no current plan of care or any physician’s orders for the new period starting from 11/12/2024 to 1/10/2025. During a joint home visit, on 11/20/2024 at 9:15 a.m., at Patient 5’s residence with a licensed vocational nurse (LVN 2), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview with Patient 5, on 11/20/2024 at 9:30am, Patient 5 stated he has different LVN’s that comes visit him at least once a week since the SOC but cannot recall the exact date the last time he was visited by RN 2. During a telephone interview, on 11/21/2024 at 10:00 a.m. with RN 2, RN 2 stated he was never notified by the HHA and did not visit and did not conduct a recertification assessment for Patient 5. During a concurrent interview and record review, on 11/21/2024 at 11:12 am, with the DPCS, Patient 4 and Patient 5’s E-chart Orders and Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 4 for the new period starting on 11/10/2024 to 1/8/2025, has no current plan of care, and Patient 4’s nursing visit clinical notes from 9/13/2024 to 11/17/2024 cannot be accessed and therefore not available for review. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 5 for the new period starting on 11/12/2025 to 1/10/2025, has no current plan of care, and Patient 5’s nursing visit clinical notes from 9/15/2024 to 11/15/2024 cannot be accessed and not available for review. The DPCS stated a recertification assessment including OASIS items should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period. The DPCS stated it was important to complete the nursing comprehensive assessment timely in order for the HHA to generate the patient’s plan of care so that skilled nurses know how to care for the patient. The DPCS stated, “If we don’t have patient’s plan of care, we don’t know how to care for the patient, which has a potential for harm in the failure to properly care for the patient.” The DPCS further stated nursing visit notes should have been submitted within 24 to 48 hours after the service was rendered per the agency’s policies. f. During a review of Patient 6’s Face Sheet, the Face Sheet indicated a SOC date of 7/29/2024, with a diagnosis that includes bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, and radiculopathy lumbar region. During a concurrent interview and record review, on 11/18/2024 at 3:20 pm, with the DPCS, Patient 6’s E-chart Orders and Nursing visit calendar was reviewed by the DPCS. The DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted for Patient 6 for the period starting from 9/27/2024 to 11/25/2024, has no current plan of care, and Patient 6’s nursing visit clinical notes from 8/9/2024 to 10/23/2024 were not available for review. The DPCS stated she does not know why nurses’ visit notes cannot be accessed and are not available for review but will call the visiting nurses to find out. The DPCS stated a follow-up comprehensive nursing assessment should have been conducted during the last 5 days of the 60-day benefit period and before the start of another 60-day period of home health services, and nursing visit notes should be submitted within 24-48 hours after the visit was conducted. During a review of the agency's undated policy and procedure (P&P) titled, Clinical/Service Data Collection, the P&P indicated home care personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. During a review of the agency’s undated P&P titled, Contents of the Clinical Records, the P&P indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. During a review of the agency's undated P&P titled, Reassessment/Recertification, the P&P indicated the comprehensive assessment must be updated and revised every 60 days beginning with the start of care. A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress towards outcomes. OASIS assessments for recertification, significant change in condition, transfer, resumption of care and discharge will be completed within the mandated time frames. For each new episode of care, a comprehensive assessment will be completed no earlier than five days before and no later than one day before the calendar day on which the new episode of care will begin. During a review of the agency's undated P&P titled, Care Planning Process, the P&P indicated a written plan of care will be initiated within 5 days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient plan of care will be developed or revised within five working days of initiation or of the reassessment of the patient. All clinicians involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the patient’s discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) was completed and filed in the clinical record for one of seven sampled patients (Patient 1). This failure resulted in Patient 1 unable to receive outpatient physical therapy services and continue to have back pain after the patient requested to be discharged from home health services. Findings: During a record review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 8/8/2024, with a primary diagnosis of essential (primary) hypertension (high blood pressure) and a secondary diagnosis of sarcopenia (age-related progressive loss of muscle mass and strength). The Face Sheet indicated Patient 1’s primary physician was Primary Physician (PP). During a record review of Patients ’s Home Health Certification and Plan of Care (POC) for the certification period starting from 10/7/2024 to 12/05/2024, the POC indicated Patient 1 had diagnosis of hypertension, sarcopenia, and polyosteoarthritis (a type of arthritis that affects multiple joints at the same time, causing cartilage and bone to degenerate). The POC indicated that Patient 1 was admitted to the HHA with Skilled Nurse (SN) frequency visits of twice a week for two weeks and then once a week for seven weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a telephone interview on 11/19/2024 at 8:34 a.m., Family Member (FM1) stated that Patient 1 had not received any discharge documentation or a call back from the home health agency. FM1 stated they called the agency multiple times, left messages, and that the HHA had not called back. FM1 stated that Patient 1 had scoliosis in her lower back, and it caused her pain all the time. FM1 stated Patient 1 received an order for physical therapy from her orthopedic surgeon (a medical professional who specializes in diagnosing and treating diseases and injuries of the musculoskeletal system) at an outpatient physical therapy clinic but was not able to be admitted because Patient 1 was not discharged from the home health agency. FM1 stated that License Vocational Nurse (LVN3) visited Patient 1 at their new address and that they told LVN3 that they wanted to be discharged so Patient 1 could go to another physical therapist. During a telephone interview on 11/19/2024 at 9:15 a.m., Patient 1 stated that she had pain in her lower back. When Patient 1 was asked to describe her pain and what her pain level was on a pain scale of 0 to 10 (0=no pain, 10=worst pain), Patient 1 stated that it was sharp and constant with a pain level of 8. Patient 1 stated that Licensed Vocational Nurse (LVN3) was the only nurse that visited her. During an interview on 11/20/2024 at 10:54 a.m., LVN3 stated the last time she visited Patient 1 was in the beginning of October 2024. LVN3 stated that she had visited Patient 1 in a skilled nursing facility several times and then the last time when Patient 1 moved into a mobile home with FM1. LVN3 stated FM1 asked that Patient 1 be discharged from home health services so she could start outpatient physical therapy with another physical therapist. LVN3 stated that Patient 1 was not able to be on outpatient physical therapy and home health services at the same time. LVN3 stated the Patient 1’s doctor called her three weeks ago and asked if the HHA discharged Patient 1, and LVN3 told her that the patient was discharged. During an interview on 11/22/2024 at 9:20 a.m., the Office Manager (OM) stated that when a patient calls and wants to be discharged, she asks the patient when they want to get discharged and then sends a registered nurse to the patient’s home to get discharged. The Office Manager stated that the patient signs the discharge order, and that paper is sent to the doctor for his signature. During an interview on 11/22/2024 at 9:48 a.m., the OM stated that the LVN3 went to the Patient’s home and the family member told that LVN that Patient 1 no longer wanted home health services because the patient wanted to go to another physical therapist. During an interview on 11/22/2024 at 10:20 a.m., Registered Nurse (RN4) stated she tried to visit Patient 1 but was not able to see the patient. RN4 stated she called FM1 multiple times but FM4 stated it was not a good time to visit the patient. RN4 stated she did not document these calls on a communication note in Patient 1’s chart. RN4 stated she did not discharge Patient 1. RN4 stated she called the HHA office and let them know she was not able to visit Patient 1, and that OM said she would take care of it. During an interview and record review on 11/22/2024 at 10:30 a.m., with the Director of Patient Care Services (DPCS), Patient 1’s Orders (section in electronic chart that shows file for physician orders and the plan of care), Nursing Visit, and Communication notes on the electronic chart were reviewed. The DPCS stated there were no communication notes regarding Patient 1’s request to be discharged, no physician order for discharge, or and there was no discharge summary with patient discharge instruction/notification. During an interview and record review on 11/22/2024 at 10:40 a.m., with the DPCS, Patient 1’s OASIS-E Discharge assessment was reviewed. The discharge assessment indicated that the patient was discharged on 10/10/2024 and that a written notice was provided for the patient. The DPCS stated that Patient 1 was an office discharge, and the discharge assessment was not correct. The DPCS stated that the Patient was not visited by a nurse and not provided a written notice. The DPCS stated that if there was an office discharge, the patient’s referring physician should be notified and a copy of the patient discharge instructions/notification forms should be mailed to the patient. The DPCS stated that it was the patient’s right to be discharged and to be notified that they are discharged from home health services. During a record review of the HHA’s (undated) policy and procedure titled, “Patient Bill of Rights,” the policy indicated that each patient will be an active, informed participant in his/her plan of care. The policy indicated that the Patient Bill of Rights statement defines the right of the patient to…M. Be able to refuse care or treatment after the consequences of refusing care or treatment are presented. Receive appropriate care without discrimination in accordance with physician orders…BB. This Organization’s transfer and discharge policies… During a record review of the HHA’s (undated) policy and procedure titled, “Care/Service Coordination,” the policy indicated that timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The policy indicated that the clinician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel. The policy indicated that written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s clinical record or interdisciplinary group meeting notes. During a record review of the HHA’s (undated) policy and procedure titled, “Discharge Criteria and Process,” the policy indicated that a discharge summary will be completed and filed in the clinical record. The policy indicated that prior notice will not be necessary when services are discontinued by the patient or physician; however, action taken must be documented in the clinical record and a discharge summary completed. A copy of the discharge instructions will be mailed to the patient. During a record review of the HHA’s (undated) policy and procedure titled, “Discharge Summary,” the policy indicated that the discharge summary and other relevant clinical record documents will be completed within 72 hours of discharge from service.