Every finding on record at Pathways Healthcare Pennsylvania LLC

Based on the findings of an unannounced, onsite Medicare recertification survey conducted January 28 through January 30, 2025, Pathways Healthcare was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted January 28 through January 30, 2025, Pathways Healthcare was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records, and based on administrative staff interview, the agency failed to ensure written instructions regarding the revised skilled nursing (SN) visit frequency were provided to three (3) of four (4) patients for whom a home visit was conducted. (Patients #2, #3 and #5) Findings include: On January 30, 2025 at approximately 2:41 PM, review of agency policy 2-004, titled "Admission Documents", revealed the following under "Procedure": 3. The admission information, including the...calendar with visit frequency will be left in the patient's home. 4. Any updates to the...visit frequency will be documented by the clinician in the patient's home prior to being printed. Patient #2: On January 28, 2025 at approximately 11:22 AM, review of the clinical record revealed the projected SN visit frequency was two (2) times a week for nine (9) weeks as documented on the admission form titled "Estimated Frequency/Duration" dated 01/16/2025. Review of the "Home Health Certification and Plan of Care" for the initial certification period of 01/16/2025 through 03/16/2025 revealed the SN visit frequency is one (1) time a week for one (1) week, two (2) times a week for two (2) weeks followed by one (1) time a week for six (6) weeks. During a home visit conducted on January 29, 2025 at approximately 8:30 AM, review of the agency's admission booklet failed to reveal that the agency had provided the patient with written instructions regarding the updated SN visit frequency which was ordered on the "Home Health Certification and Plan of Care". Patient #3: On January 28, 2025 at approximately 11:55 AM, review of the clinical record revealed the projected SN visit frequency was two (2) times a week for four (4) weeks as documented on the admission form titled "Estimated Frequency/Duration" form dated 10/25/2024 Review of the "Home Health Certification and Plan of Care" for the recertification period of 12/24/2024 through 02/21/2025 revealed the SN visit frequency is two (2) times a week for five (5) weeks followed by one (1) time a week for four (4) weeks. During a home visit conducted on January 29, 2025 at approximately 9:20 AM, review of the agency's admission booklet failed to reveal that the agency had provided the patient with written instructions regarding the updated SN visit frequency which was ordered on the "Home Health Certification and Plan of Care". Patient #5: On January 28, 2025 at approximately 1:46 PM, review of the clinical record revealed the projected SN visit frequency was two (2) times a week for two (2) weeks as documented on the admission form titled "Estimated Frequency/Duration" form dated 12/12/2024. Review of the "Home Health Certification and Plan of Care" for the initial certification period of 12/12/2024 through 02/09//2025 revealed the SN visit frequency is one (1) time a week for one (1) week, two (2) times a week for two (2) weeks followed by one (1) time a week for six (6) weeks. During a home visit conducted on January 29, 2025 at approximately 11:30 AM, review of the agency's admission booklet failed to reveal that the agency had provided the patient with written instructions regarding the updated SN visit frequency which was ordered on the "Home Health Certification and Plan of Care". During interview conducted on January 30, 2025 at approximately 2:45 PM, the Administrator (Employee #11), the Chief Operating Officer (Employee #12) and the Vice President of Clinical Operations (Employee #13) confirmed there was no documentation which provided evidence that the agency had provided the above identified patients with written instructions regarding the updated SN visit frequency which was ordered on the "Home Health Certification and Plan of Care".

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records, and based on administrative staff interview, the agency failed to ensure written instructions regarding the medication schedule/instructions had been provided to two (2) of four (4) patients for whom a home visit was conducted. (Patients #2 and #5) Findings include: On January 30, 2025 at approximately 2:41 PM, review of agency policy 2-004, titled "Admission Documents", revealed the following under "Procedure": 3. The admission information, including the reconciled medication sheet...will be left in the patient's home. 4. Any updates to the medication list...will be documented by the clinician in the patient's home prior to being printed. Patient #2: On January 28, 2025 at approximately 11:22 AM, review of the clinical record revealed a total of nine (9) medications, including heparin and normal saline intravenous flushes and meclizine (medication to treat dizziness), were ordered on the "Home Health Certification and Plan of Care" for the initial certification period of 01/16/2025 through 03/16/2025. During a home visit conducted on January 29, 2025 at approximately 8:30 AM, review of healthcare provider documentation provided by the patient revealed a partial list of the patient medications were included on the form titled "Patient Discharge Instructions". The "Patient Discharge Instructions" form was dated 01/24/2025 and did not include instructions regarding heparin and saline flushes nor meclizine. Review of the agency's admission folder revealed there was no documentation which provided evidence the agency had provided the patient with written instructions regarding the heparin and saline intravenous flushes and meclizine which were ordered on the "Home Health Certification and Plan of Care". Patient #5: On January 28, 2025 at approximately 1:46 PM, review of the clinical record revealed a total of six (6) medications were ordered on the "Home Health Certification and Plan of Care" for the initial certification period of 12/12/2024 through 02/09/2025. During a home visit conducted on January 29, 2025 at approximately 11:30 AM, review of the agency's admission folder revealed there was no documentation which provided evidence the agency had provided the patient with written instructions regarding the medication schedule/instructions which were ordered on the "Home Health Certification and Plan of Care". During interview conducted on January 30, 2025 at approximately 2:45 PM, the Administrator (Employee #11), the Chief Operating Officer (Employee #12) and the Vice President of Clinical Operations (Employee #13) confirmed there was no documentation which provided evidence that the agency had provided the above identified patients with written instructions regarding the aforementioned medication schedule/instructions which were ordered on the "Home Health Certification and Plan of Care".

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, initial tuberculosis (TB) screening guidance from the Centers for Disease Control (CDC) and Pennsylvania Department of Health (PA DOH), clinical records and personnel files and based administrative staff interview, the agency failed to ensure initial TB screening was conducted in accordance with agency policies/procedures and CDC and PA DOH recommendations for seven (7) of seven (7) active employees whose date of hire was after January 21, 2022. (Employees #1, #3, #6, #7, #8, #9 and #10) Finding include: On January 30, 2025 at approximately 2:34 PM, review of agency policy 1-005, titled "Categories/Qualifications of Personnel", revealed the following under "Health Requirements": 1. Personnel with Patient Contact: All new personnel who will be in contact with patients...must undergo a physical screening before they are employed...In addition, personnel must have a Mantoux (TB skin test-TST) text or show evidence that there is no active TB in the past 12 months by providing a copy of a negative Mantoux/TB test within the past 12 months prior to providing care. On January 30, 2025 at approximately 2:39 PM, review of agency policy 6-028, titled "Tuberculosis Exposure Control Plan", revealed the following: Purpose: To provide guidelines to reduce the risk of occupational exposure to TB. Procedure...2. Where required by state...regulations, a two (2) step TST will be given for all personnel upon hire if no TST has been performed within 12 months of hire date... On January 30, 2025 at approximately 3:35 PM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/index.html The TB screening process for health care personnel includes: -A baseline individual TB risk assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step)). On January 30, 2025 at approximately 3:50 PM, review the PA DOH webpage ( https://www.pa.gov/agencies/health/diseases-conditions/infectious-disease/tuberculosis/tb-testing-health-care-workers.html ) revealed the following: Tuberculosis Testing Health Care Workers...On May 17, 2019 the Centers for Disease Control and Prevention (CDC) issued updated recommendations for TB testing of health care personnel. Key points include: On May 17, 2019 the Centers for Disease Control and Prevention (CDC) issued updated recommendations for TB testing of health care personnel. Key points include: \r\n \r\n\r\nThe updated recommendations call for health care personnel to be screened for TB upon hire with an individual risk assessment, a symptom evaluation, and a TB test (either the interferon gamma-release assay, or IGRA, blood test or the tuberculin skin test). Thereafter, annual TB testing is not recommended unless there is a known exposure to a case of infectious TB disease or there is ongoing transmission in the health care setting where the individual works.\r\nA positive TB test indicates that a person has been infected with TB bacteria. It does not specify whether the person has latent TB infection (LTBI) or has progressed to TB disease. Anyone with a newly positive TB test should receive a symptom evaluation and chest x-ray to rule out TB disease. Additional workup may be needed based on these results.\r\nTreatment for latent TB infection is strongly encouraged for health care personnel diagnosed with LTBI. Shorter treatment regimens, such as once-weekly isoniazid and rifapentine for 3 months or daily rifampin for 4 months, should be used as they are more likely to be completed when compared to the traditional regimens of 6 or 9 months of isoniazid.\r\nHealth care personnel that have been diagnosed with LTBI and declined treatment should receive an annual TB symptom screen to detect early evidence of TB disease and to reevaluate the risks and benefits of LTBI treatment. If the benefit of treatment is expected to exceed the risk, the health care worker should continue to be strongly encouraged to complete LTBI treatment.\r\nThe CDC recommends that all health care personnel receive TB education annually. The PA TB program has prepared a presentation for health care personnel that reviews TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. Consistent with CDC guidance, the presentation also emphasizes that health care personnel diagnosed with LTBI are strongly encouraged to complete preventive treatment..\r\nLastly, the above information updates the recommendations for TB screening and testing of health care personnel from the 2005 CDC Guidelines on Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings. All other aspects of the 2005 guidelines, including infection control practices and facility risk assessments, remain in effect.  \r\n\r\nFor additional resources from the CDC, visit the TB Screening and Testing of Health Care Personnel page on the CDC website. \r\nIf you have any questions about TB testing call the PA TB program at 717-787-6267. \r\n \r\n \r\n \r\n \r\n"}}"> The updated recommendations call for health care personnel to be screened for TB upon hire with an individual risk assessment(opens in a new tab), a symptom evaluation, and a TB test(opens in a new tab) (either the interferon gamma-release assay, or IGRA, blood test or the tuberculin skin test). On January 30, 2025 at approximately 3:55 PM, review of the PA DOH TB manual ( https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/diseases-and-conditions/tb/CMHD%20TB%20Manual%202023.pdf ) revealed the following: LAWS PERTAINING TO TB CONTROL...Pennsylvania laws on TB can be found in the Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, 35 P.S. Sec. 521.1 . Under the provisions of the Pennsylvania Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, DOH has the authority to “protect the health of the people of this Commonwealth, and to determine and employ the most efficient and practical means for the prevention and suppression of disease.” Patient #1 (Discharge): On January 28, 2025 at approximately 10:14 AM, review of the clinical record revealed the registered nurse (RN-Employee #6) provided skilled nursing (SN) services in September 2024. Patient #2: On January 28, 2025 at approximately 11:22 AM, review of the clinical record revealed the RN (Employee #1) provided SN services in January 2025. Patient #4: On January 28, 2025 at approximately 12:28 PM, review of the clinical record revealed the occupational therapist (OT-Employee #7) provided services in December 2024 and January 2025. Patient #5: On January 28, 2025 at approximately 1:46 PM, review of the clinical record revealed the PT (Employee #3) provided PT services in December 2024 and January 2025. Patient #6 (Discharge): On January 30, 2025 at approximately 10:56 AM, review of the clinical record revealed the certified occupational therapy assistant (COTA-Employee #8), the physical therapy assistant (PTA-Employee #9) and the social worker (SW-Employee #10) provided services in September 2024. Between January 29, 2025 at approximately 1;44 PM and January 30, 2025 at approximately 1:36 PM, review of personnel file documentation revealed the following: Employee #1: The date of hire of the RN was 07/17/2023, that the first date of assignment to provide SN services was 07/19/2023 and that a single step TST was completed on 10/10/2023. There was no documentation in the personnel file which provided evidence the first step of the TST was completed prior to the assignment to provide SN service nor was documentation present which provided evidence the second step TST had been completed. Employee #3: The date of hire of the PT was 08/14/2023, that the first date of assignment to provide PT services was 08/23/2023 and that a single step TST was completed on 08/23/2023. There was no documentation in the personnel file which provided evidence the second step TST had been completed. Employee #6: The date of hire of the RN was 08/01/2024, that the first date of assignment to provide SN services was 08/15/2024 and that a single step TST was completed on 01/27/2025. There was no documentation in the personnel file which provided evidence the first step TST was completed prior to the assignment to provide SN services nor was documentation present which provided evidence a second step TST had been completed. Employee #7: The date of hire of the OT was 08/07/2023, that the first date of assignment to provide OT services was 08/23/2023 and that a single step TST was completed on 08/07/2023. There was no documentation in the personnel file which provided evidence the second step TST had been completed. Employee #8: The date of hire of the COTA was 08/19/2024, that the first date of assignment to provide OT services was 08/29/2024 and that a single step TST was completed on 08/19/2024. There was no documentation in the personnel file which provided evidence the second step TST had been completed. Employee #9: The date of hire of the PTA was 02/13/2023, that the first date of assignment to provide PT services was 02/21/2023 and that a single step TST was completed on 01/27/2025. There was no documentation in the personnel file which provided evidence that the TST screening process was initiated prior to the assignment to provide services on 02/21/2023. Employee #10: The date of hire of the SW was 02/06/2023, that the first date of assignment to provide SW services was 02/13/2023 and that the SW reported a TST test was completed on 09/01/2023 as documented on the TB questionnaire dated 09/12/2024. There was no documentation in the personnel file which provided evidence a two (2) step TST had been completed. During interview conducted on January 30, 2025 at approximately 2:45 PM, the Administrator (Employee #11), COO (Employee #12) and the Vice President of Clinical Operations (Employee #13) confirmed initial TB screening was not conducted in accordance with agency policy/procedure nor CDC and PA DOH recommendations for the above referenced employees.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted January 19 through January 21, 2022, Pathways Healthcare was found not to be in compliance with the requirement of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on observation and review of agency policies/procedures, clinical records, personnel files and documentation, and based on interview with the administrator/clinical manager-supervisor (employee #1) and the chief operating officer (COO-employee #10), the agency failed to ensure two (2) of two (2) hazard vulnerability assessments (HVA) included an event type/category for agency staffing shortages. (2021 and 2022 HVA) Findings included: On January 19, 2022 at approximately 3:36 PM, review of agency policy 6-037, titled "Emergency Management Plan", revealed the following: Purpose...To establish a plan which allows for the continuation of services in the event of a disaster affecting the organization or community. Definitions...2. Hazard Vulnerability Analysis: The identification of potential emergencies and the direct and indirect effects of these emergencies may have on the health care organization's operations and demand for services... Policy...Planning Process: Organization leadership will conduct a hazard vulnerability analysis to identify potential emergencies that could affect the need for services or the ability to provide services... On January 19, 2022 at approximately 11:22 AM, upon arrival at the agency office, the door was noted to be locked. There was no answer after knocking at the door. Exterior postings indicated that the office hours are 8:00 AM to 5:00 PM. At approximately 11:26 AM, a call was placed to the agency telephone number listed in the PA DOH database. The person who answered the telephone call indicated that the staff member was located in Massachusetts. The staff member transferred the call to the administrator/clinical manager (employee #1) at which time the call was transferred to voicemail. A message was left requesting that employee #1 return the call. At approximately 11:36 AM, a call was received from the employee #1. Employee #1 reported that the clerical staff member is working remotely and that all calls for the agency are answered by the Massachusetts’ office. Employee #1 reported that employee #1 was currently performing a patient visit and that employee #1 would return to the agency office as soon as the patient visit was completed. At approximately 11:47 AM, a call was received from an agency COO (employee #10). The telephone number location for employee #10 was listed as Hingham, MA. Employee #10 reported that employee #1 would return to the office after completion of the patient visit. At approximately 12:00 noon, employee #1 arrived at the agency office. Between January 20, 2022 at approximately 1:20 PM and January 21, 2022 at approximately 10:03 AM, review of personnel files revealed the following: Employee #1: The date of hire of the registered nurse (RN)/administrator/clinical manager/clinical supervisor was October 10/09/2017. Clinical record review findings for the administrator/RN clinical manager-supervisor (employee #1): Patient #2: On January 20, 2022 at approximately 6:28 PM, review of the clinical record revealed the start of care date was 01/11/2022, the primary diagnosis is sepsis and that skilled nursing (SN) services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 01/11/2022 through 03/11/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the start of care SN visit on 01/11/2022. Review of "Client Calendar Report" documentation revealed employee #1 is scheduled to perform the recertification SN visit on 03/08/2022. Patient #4: On January 20, 2022 at approximately 7:31 PM, review of the clinical record revealed the start of care date was 01/18/2022, the primary diagnosis is chronic obstructive pulmonary (lung) disease (COPD) and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 01/18/2022 through 03/18/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the start of care SN visit on 01/18/2022. Patient #5: On January 21, 2022 at approximately 10:40 AM, review of the clinical record revealed the start of care date was 02/04/2021, the primary diagnosis is acute on chronic systolic (congestive) heart failure and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the recertification period of 12/01/2021 through 01/29/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) provided routine SN services on 12/07/2021, 12/21/2021, 12/31/2021, 01/04/2022 and 01/19/2022 (Wednesday). Review of "Client Calendar Report" documentation revealed employee #1 is scheduled to perform the recertification SN visit on 01/25/2022. Patient #6: On January 21, 2022 at approximately 11:53 AM, review of the clinical record revealed the start of care date was 06/12/2021, the primary diagnosis is Type-2 diabetes mellitus with diabetic ophthalmic (eyes) complications and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the recertification period of 12/09/2021 through 02/06/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the SN recertification visit on 12/08/2021 (Wednesday). Review of "Client Calendar Report" documentation revealed employee #1 is scheduled to perform the recertification SN visit on 02/02/2022 (Wednesday). Patient #8: On January 21, 2022 at approximately 12;26 PM, review of the clinical record revealed the start of care date was 11/27/2021, the primary diagnosis is acute ischemic (weakened muscles) heart disease and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 11/27/2021 through 01/25/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the start of care SN visit on 11/27/2021. On January 19, 2022 at approximately 2:33 PM, review of the emergency preparedness plan failed to reveal that agency staffing shortages had been included as an event type/category on the 2021 and 2022 HVA forms. An interview was conducted with the administrator/clinical manager-supervisor (employee #1) and the COO (employee #10) on January 21, 2022 at approximately 3:40 PM. During the interview, the administrator/RN clinical manager-supervisor (employee #1) reported that employee #1 is providing SN services due to staffing shortages. Employee #1 and the COO confirmed that agency staffing shortages was not included as an event type/category on the 2021 and 2022 HVA forms.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted January 19 through January 21, 2022, Pathways Healthcare was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator/clinical manager-supervisor (employee #1) and the chief operating officer (COO-employee #10), the agency failed to ensure two (2) of two (2) patients who were discharged for cause (involuntarily) were provided notification that the agency is required to make efforts to resolve the problems prior to discharging a patient due to behavioral issues/non-compliance with the home health plan of care. (Patients #9 and #10) Findings include: On January 21, 2022 at approximately 3:04 PM, review of agency policy 2-002, titled "Patient Bill of Rights" revealed the following: Purpose...To encourage awareness of patient rights and provide guidelines to assist patients in making decisions regarding care and for active participation in care planning... Procedure...1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care, of their rights. 2. The Patient Bill of Rights statement defines the right of the patient to... AA. The organization's transfer and discharge policies... On January 21, 2022 at approximately 3:18 PM, review of agency policy 4--045, titled "Discharge Criteria and Process" revealed the following: Purpose...To outline the process to discharge a patient from service... Policy...Discharge/Reduction of Services Criteria... 1. Services will be terminated when the patient meets one (1) or more of the discharge criteria... G. The patient and/or family display disruptive, abusive, and uncooperative behavior... Procedure... 5...Efforts to resolve problems prior to discharge will also be documented in the patient's record... On January 19, 2022 at approximately 1:13 PM, review of the patient admission information packet/"Patient Rights and Responsibilities" form failed to reveal that a copy of the "Discharge Criteria and Process" policy was included the admission packet and that there was no documentation on the "Patient Rights and Responsibilities" form included notification that the agency was required to maintain documentation of efforts to resolve problems prior to discharging a patient for behavioral issues/non-compliance with the home health plan of care. #9: On January 21, 2022 at approximately 1:05 PM, review of the clinical record revealed the start of care date was 03/04/2021, the primary diagnosis was orthostatic hypotension (drop in blood pressure with position changes) and that SN, physical therapy (PT) and occupational therapy (OT) services were to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 03/04/2021 through 05/02/2021. Review of interim order documentation revealed social work (MSW) services were to be provided one (1) time a week for one (1) week. Review of visit note/communication note documentation revealed the following: PT services were provided on 03/09/2021 and the patient requested that no further PT visits be provided after 03/09/2021; OT services were effective 03/10/2021; MSW services were provided on 03/26/2021; and SN services were provided on 03/04, 03/08, 03/11, 03/15, 03/17, 03/23, 03/26, 03/30, 04/06, 04/15 and 04/20/2021. The licensed practical nurse (LPN-employee #3) documented that not all of the patient's medications were available in the home and that the patient was experiencing financial issues. On 04/25/2021, the LPN (employee #3) documented that the patient drove 1.5 hours to a family member's home and was disoriented but that the patient refused to be transported to the hospital for evaluation. On 04/29/2021, an RN (employee #12) documented that "clinical leadership" and the patient's physician were made aware that the patient was being discharged from the agency. The RN documented that the patient was being discharged due to non-compliance, refused OT/PT services, refuses MSW assistance, refuses to take medications due to financial issues. The RN documented that discharge forms were signed. There was no documentation in the clinical record which provided evidence that the agency was considering discharging the patient due to the above referenced problems prior to 04/29/2021 and there was no documentation which provided evidence that the agency attempted to resolve the above referenced problems prior to 04/29/2021. There was no documentation in the electronic patient rights signature forms which provided evidence that the patient was notified the agency is required to make efforts to resolve problems prior to discharging a patient due to behavioral issues/non-compliance with the home health plan of care. #10: On January 21, 2022 at approximately 1:50 PM, review of the clinical record revealed the start of care date was 03/16/2021, the primary diagnosis was Type-2 diabetes mellitus (diabetes) with chronic kidney disease and that SN, PT, OT and MSW services were to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 03/16/2021 through 05/13/2021. Review of visit note/communication note documentation revealed the following: PT services were provided on 03/17, 03/31, 04/02, 04/07 and 04/09/2021. OT services were refused effective 03/24/2021; MSW services were provided on 03/28/2021; and SN services were provided on 03/16, 03/23, 03/26, 03/29 and 04/08/2021. Clinical record documentation revealed the patient was hospitalized on 04/13/2021 due to falls/deep vein thrombosis (blood clot). Resumption of care orders dated 05/01/2021 revealed SN, PT and OT services were to be provided. Review of visit note/communication note documentation revealed the following: PT services were refused effective 05/07/2021; OT services were provided on 05/05/2021; SN services were provided on 05/01 and 05/06/2021. Review of resumption of care visit note documentation dated 05/01/2021 revealed the RN (employee #13) documented that the patient's past medical history included alcohol use, depression and that the patient was occasionally incontinent of urine (unable to control bladder). On 05/06/2021, the LPN (employee #3) documented that the patient was occasionally forgetful, that feces (BM)/urine stains were present on the floors and bed, that dirty dishes were present in the sink, that the patient was intoxicated upon the LPN's arrival, that the patient had fallen which resulted in a head wound and that the patient was transferred to the hospital for treatment where a scan of the head was performed and four (4) staples were inserted to close the head wound. The LPN documented that the patient signed out of the emergency department. The LPN also documented that the patient is "verbally abusive and combative" when intoxicated, that the patient refuses to cease alcohol consumption and that the patient is non-compliant with teaching and care. On 05/10/2021, an office employee (employee #14) documented that the patient was being discharged from the agency due to non-compliance with the plan of care, alcohol abuse and verbal abuse of the clinician. On 05/12/2021, an RN (employee #13) documented that the patient's family member was unhappy/aggressive during a telephone call in which the family member expressed concern about the patient's discharge from the agency and that the family member voiced concerns as to whom would remove the staples which were still present in the patient's head wound. The RN documented that the patient would continually call SN staff when intoxicated. There was no documentation which provided evidence that the agency attempted to resolve the above referenced problems prior to 05/10/2021. There was no documentation in the electronic patient rights signature forms which provided evidence that the patient was notified the agency is required to make efforts to resolve problems prior to discharging a patient due to behavioral issues/non-compliance with the home health plan of care. During interview conducted on January 21, 2022 at approximately 3:40 PM, the administrator/clinical manager-supervisor and COO confirmed the patient rights signature forms did not include notification that the agency is required to make efforts to resolve problems prior to discharging a patient due to behavioral issues/non-compliance with the home health plan of care.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator/clinical manager-supervisor (employee #1) and the chief operating officer (COO-employee #10), the agency failed to ensure two (2) of two (2) patients who were discharged for cause (involuntarily) were provided notification that the agency was required to provide the names and contact information for other agencies/providers which would be available to provide home health services prior to discharging a patient due to behavioral issues/non-compliance with the home health plan of care. (Patients #9 and #10) Findings include: On January 21, 2022 at approximately 3:04 PM, review of agency policy 2-002, titled "Patient Bill of Rights" revealed the following: Purpose...To encourage awareness of patient rights and provide guidelines to assist patients in making decisions regarding care and for active participation in care planning... Procedure...1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care, of their rights. 2. The Patient Bill of Rights statement defines the right of the patient to... AA. The organization's transfer and discharge policies... On January 21, 2022 at approximately 3:18 PM, review of agency policy 4--045, titled "Discharge Criteria and Process" revealed the following: Purpose...To outline the process to discharge a patient from service... Policy...Discharge/Reduction of Services Criteria... 1. Services will be terminated when the patient meets one (1) or more of the discharge criteria... G. The patient and/or family display disruptive, abusive, and uncooperative behavior... Procedure... 5...The patient will be provided contact information for other home health agencies and providers if continued care is needed... On January 19, 2022 at approximately 1:13 PM, review of the patient admission information packet/"Patient Rights and Responsibilities" form failed to reveal that a copy of the "Discharge Criteria and Process" policy was included the admission packet and that there was no documentation on the "Patient Rights and Responsibilities" form included notification that the agency was required to provide the names and contact information for other agencies/providers which would be available to provide home health services. #9: On January 21, 2022 at approximately 1:05 PM, review of the clinical record revealed the start of care date was 03/04/2021, the primary diagnosis was orthostatic hypotension (drop in blood pressure with position changes) and that SN, physical therapy (PT) and occupational therapy (OT) services were to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 03/04/2021 through 05/02/2021. Review of interim order documentation revealed social work (MSW) services were to be provided one (1) time a week for one (1) week. Review of visit note/communication note documentation revealed the following: PT services were provided on 03/09/2021 and the patient requested that no further PT visits be provided after 03/09/2021; OT services were effective 03/10/2021; MSW services were provided on 03/26/2021; and SN services were provided on 03/04, 03/08, 03/11, 03/15, 03/17, 03/23, 03/26, 03/30, 04/06, 04/15 and 04/20/2021. The licensed practical nurse (LPN-employee #3) documented that not all of the patient's medications were available in the home and that the patient was experiencing financial issues. On 04/25/2021, the LPN (employee #3) documented that the patient drove 1.5 hours to a family member's home and was disoriented but that the patient refused to be transported to the hospital for evaluation. On 04/29/2021, an RN (employee #12) documented that "clinical leadership" and the patient's physician were made aware that the patient was being discharged from the agency. The RN documented that the patient was being discharged due to non-compliance, refused OT/PT services, refuses MSW assistance, refuses to take medications due to financial issues. There was no documentation in the electronic patient rights signature forms which provided evidence that the patient was notified the agency is required to provide the names and contact information for other agencies/providers which would be available to provide home health services. #10: On January 21, 2022 at approximately 1:50 PM, review of the clinical record revealed the start of care date was 03/16/2021, the primary diagnosis was Type-2 diabetes mellitus (diabetes) with chronic kidney disease and that SN, PT, OT and MSW services were to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 03/16/2021 through 05/13/2021. Review of visit note/communication note documentation revealed the following: PT services were provided on 03/17, 03/31, 04/02, 04/07 and 04/09/2021. OT services were refused effective 03/24/2021; MSW services were provided on 03/28/2021; and SN services were provided on 03/16, 03/23, 03/26, 03/29 and 04/08/2021. Clinical record documentation revealed the patient was hospitalized on 04/13/2021 due to falls/deep vein thrombosis (blood clot). Resumption of care orders dated 05/01/2021 revealed SN, PT and OT services were to be provided. Review of visit note/communication note documentation revealed the following: PT services were refused effective 05/07/2021; OT services were provided on 05/05/2021; SN services were provided on 05/01 and 05/06/2021. Review of resumption of care visit note documentation dated 05/01/2021 revealed the RN (employee #13) documented that the patient's past medical history included alcohol use, depression and that the patient was occasionally incontinent of urine (unable to control bladder). On 05/06/2021, the LPN (employee #3) documented that the patient was occasionally forgetful, that feces (BM)/urine stains were present on the floors and bed, that dirty dishes were present in the sink, that the patient was intoxicated upon the LPN's arrival, that the patient had fallen which resulted in a head wound and that the patient was transferred to the hospital for treatment where a scan of the head was performed and four (4) staples were inserted to close the head wound. The LPN documented that the patient signed out of the emergency department. The LPN also documented that the patient is "verbally abusive and combative" when intoxicated, that the patient refuses to cease alcohol consumption and that the patient is non-compliant with teaching and care. On 05/10/2021, an office employee (employee #14) documented that the patient was being discharged from the agency due to non-compliance with the plan of care, alcohol abuse and verbal abuse of the clinician. On 05/12/2021, an RN (employee #13) documented that the patient's family member was unhappy/aggressive during a telephone call in which the family member expressed concern about the patient's discharge from the agency and that the family member voiced concerns as to whom would remove the staples which were still present in the patient's head wound. There was no documentation in the electronic patient rights signature forms which provided evidence that the patient was notified the agency is required to provide the names and contact information for other agencies/providers which would be available to provide home health services. During interview conducted on January 21, 2022 at approximately 3:40 PM, the administrator/clinical manager-supervisor and COO confirmed the patient rights signature forms did not include notification that the agency is required to provide the names and contact information for other agencies/providers which would be available to provide home health services.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures and clinical record documentation, and interview with the administrator/clinical manager-supervisor (employee #1) and the chief operating officer (COO-employee #10), the agency failed to obtain a physician order for a revised start of care date for five (5) of ten (10) patients for whom the initial assessment was completed more than 48 hours after referral or inpatient discharge. (Patients #2, #3, #4, #8 and #9) Findings include: On January 21, 2022 at approximately 3:05 PM, review of agency policy 2-003 titled "Admission Criteria and Process" revealed the following: Purpose...To establish standards and a process by which a patient can be evaluated and accepted for admission. Procedure... 2. The clinical manager will assign clinical organization personnel to conduct initial assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from referring facility. A. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return home, or on the start of care date ordered by the physician (or other licensed independent practitioner.) Patient #2: On January 20, 2022 at approximately 6:28 PM, review of the clinical record revealed the start of care date was 01/11/2022, the primary diagnosis is sepsis and that skilled nursing (SN) services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 01/11/2022 through 03/11/2022. Review of electronic document attachments revealed the physician referral was dated 01/04/2022. There was no documentation on the referral which provided evidence that the patient was discharged from an inpatient facility. Interim physician order documentation dated 01/05/2022 revealed a physician order was obtained to admit the patient to home health services. Review of SN visit note documentation revealed the start of care (initial) SN assessment visit was performed on 01/11/2022 which was seven (7 days after the referral date and six (6) days after the date the interim physician order was obtained. There was no documentation in the clinical record which provided evidence that the agency obtained a physician order for a revised start of care date of 01/11/2022. Patient #3: Between January 20, 2022 at approximately 6:41 PM and January 21, 2022 at approximately 11:38 AM, review of the clinical record revealed the start of care date was 09/17/2021, the primary diagnosis is unspecified B-cell lymphoma and that skilled nursing (SN) services are to be provided as documented on the "Home Health Plan of Care & Certification" for the recertification period of 01/15/2022 through 03/15/2022. Review of electronic document attachments revealed the physician referral was dated 09/14/2021. There was no documentation on the referral which provided evidence that the patient was discharged from an inpatient facility. Review of SN visit note documentation revealed the start of care (initial) SN assessment visit was performed on 09/17/2021 which was more than 48 hours after the referral date. There was no documentation in the clinical record which provided evidence that the agency obtained a physician order for a revised start of care date of 09/17/2021. Patient #4: On January 20, 2022 at approximately 7:31 PM, review of the clinical record revealed the start of care date was 01/18/2022, the primary diagnosis is chronic obstructive pulmonary (lung) disease (COPD) and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 01/18/2022 through 03/18/2022. Review of electronic document attachments revealed the physician referral was dated 01/25/2022. There was no documentation on the referral which provided evidence that the patient was discharged from an inpatient facility. Interim physician order documentation dated 01/17/2022 revealed a physician order was obtained to admit the patient to home health services. Review of SN visit note documentation revealed the start of care (initial) SN assessment visit was performed on 01/18/2022 which was more than 48 hours after the referral date. There was no documentation in the clinical record which provided evidence that the agency obtained a physician order for a revised start of care date of 01/18/2022. Patient #8: On January 21, 2022 at approximately 12;26 PM, review of the clinical record revealed the start of care date was 11/27/2021, the primary diagnosis is acute ischemic (weakened muscles) heart disease and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 11/27/2021 through 01/25/2022. Review of electronic document attachments revealed the physician referral and inpatient discharge date was 11/24/2021. Review of SN visit note documentation revealed the start of care (initial) SN assessment visit was performed on 11/27/2021 which was more than 48 hours after the referral/inpatient discharge date. There was no documentation in the clinical record which provided evidence that the agency obtained a physician order for a revised start of care date of 11/27/2021. Patient #9: On January 21, 2022 at approximately 1:05 PM, review of the clinical record revealed the start of care date was 03/04/2021, the primary diagnosis orthostatic hypotension (drop in blood pressure with position changes) and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 03/04/2021 through 05/02/2021. Review of electronic document attachments revealed the physician referral date was 03/01/2021. There was no documentation on the referral which provided evidence that the patient was discharged from an inpatient facility. Interim physician order documentation dated 03/01/2021 revealed a physician order was obtained to evaluate the patient for home health services. Review of SN visit note documentation revealed the start of care (initial) SN assessment visit was performed on 03/04/2021 which was more than 48 hours after the referral/inpatient discharge date. There was no documentation in the clinical record which provided evidence that the agency obtained a physician order for a revised start of care date of 03/04/2021. During interview conducted on January 21, 2022 at approximately 3:40 PM, the administrator/clinical manager-supervisor and COO confirmed there was no documentation in the clinical record which provided evidence that a physician order for a revised start of care date had been obtained for the above identified patients.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, documentation, personnel files, and Pennsylvania (PA) Department of Health (DOH) website reports, and based on interview with the administrator/clinical manager-supervisor (employee #1) and the chief operating officer (COO-employee #10), the agency failed to submit two (2) of two (2) COVID-19 related reports to the PA DOH Event Reporting System (ERS) website prior to January 19, 2022. Findings include: On January 19, 2022 at approximately 3:40 PM, review of agency policy 5-005, titled "Incident Reporting", revealed the following: Purpose...To define the reporting...process for incidents involving patients and organization personnel. Procedure...6. Incidents requiring report to state...regulatory agency: C. As applicable, the Performance Improvement Coordinator or designee will complete and submit the necessary forms with the required time frame to the appropriate organization... On January 21, 2022 at approximately 7:30 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed Activation of Internal or External Emergency Plan and Health Department Reportable Diseases, subcategory COVID-19, are PA DOH reportable events. On January 19, 2022 at approximately 2:33 PM, review of the "COVID-19 Emergency Plan" revealed the agency emergency preparedness plan was activated by the agency on February 29, 2020 as a result of a COVID-19. On January 20, 2022 at approximately 3:12 PM, review of electronic health file information revealed the physical therapist/alternate to the clinical manager (employee #8) tested positive for COVID-19 on 11/24/2020. On January 19, 2022 at approximately 8:30 AM, review of the PA DOH ERS website failed to reveal that the agency had submitted a report of activation of the COVID-19 emergency plan, nor the COVID-19 positive result for employee #8, to the PA DOH ERS website prior to 01/19/2022. During interview on January 21, 2022 at approximately 3:40 PM, the administrator//clinical manager-supervisor and the COO confirmed the agency failed to submit reports of the above referenced incidents to the PA DOH ERS website prior to 01/19/2022.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on observation and review of agency policies/procedures, documentation, clinical records, personnel files and Pennsylvania (PA) Department of Health (DOH) state licensure regulations 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601, and based on interview with the administrator/clinical manager (employee #1) and the chief operating officer (COO-employee #10), the agency failed to ensure a similarly qualified alternate to supervising RN (clinical manager) was available during the regular operating hours of the agency when the clinical manager was not available. Findings include: On January 21, 2022 at approximately 3:07 PM, review of agency policy 1-025, titled "Scope of Services" revealed the following: Purpose...To describe Pathways Healthcare operations... Policy...Pathways Healthcare will operate an office that will provide a safe and adequate location related to...administrative services...Pathways Healthcare will be open from 8:30 AM to 4:00 PM, Monday through Friday, except designated holidays or other days decided by the Executive Director. Designated organization personnel will be available to patients on an on-call basis during non-office hours... On January 20, 2022 at approximately 1:23 PM, review of the "Clinical Manager" job description revealed the following: Job Description Summary...The Clinical Manager is responsible for the overall direction of home health clinical services...The Clinical Director also services as the Clinical Manager for the purposes of meeting the Medicare Conditions of Participation. On January 21, 2022 at approximately 10:05 AM, review of the "Alternate Clinical Supervisor" job description revealed the following: Job Description Summary...The Clinical Supervisor is responsible for ensuring patient care is coordinated and managed appropriately. The Clinical Supervisor is responsible for ensuring that care and services are delivered appropriately as well as the supervision of clinical personnel... Position Qualifications...1. Registered nurse with current licensure to practice professional nursing in the state... On January 20, 2022 at approximately 6:20 PM, review of 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601 revealed the following: (e) Supervising physician or registered nurse. The skilled nursing and other therapeutic services provided shall be under the supervision and direction of a physician or a registered nurse with at least 1 year of nursing experience. This person, or a similarly qualified alternate, shall be available at all times during the operating hours and participate in activities relevant to the professional services provided, including the development of qualifications and assignments of personnel. On January 19, 2022 at approximately 11:22 AM, upon arrival at the agency office, the door was noted to be locked. There was no answer after knocking at the door. Exterior postings indicated that the office hours are 8:00 AM to 5:00 PM. At approximately 11:26 AM, a call was placed to the agency telephone number listed in the PA DOH database. The person who answered the telephone call indicated that the staff member was located in Massachusetts. The staff member transferred the call to the administrator/clinical manager (employee #1) at which time the call was transferred to voicemail. A message was left requesting that employee #1 return the call. At approximately 11:36 AM, a call was received from the employee #1. Employee #1 reported that the clerical staff member is working remotely and that all calls for the agency are answered by the Massachusetts’ office. Employee #1 reported that employee #1 was currently performing a patient visit and that employee #1 would return to the agency office as soon as the patient visit was completed. At approximately 11:47 AM, a call was received from an agency COO (employee #10). The telephone number location for employee #10 was listed as Hingham, MA. Employee #10 reported that employee #1 would return to the office after completion of the patient visit. At approximately 12:00 noon, employee #1 arrived at the agency office. On January 19, 2022 at approximately 2:28 PM, review of "Organizational Chart" documentation revealed employee #1 was identified as administrator/clinical manager and clinical supervisor and that a physical therapist (employee #8) was identified as the alternate clinical supervisor/manager. Between January 20, 2022 at approximately 1:20 PM and January 21, 2022 at approximately 10:03 AM, review of personnel files revealed the following: Employee #1: The date of hire of the registered nurse (RN)/administrator/clinical manager/clinical supervisor was October 10/09/2017. Employee #2: The date of hire of the RN was 10/16/2017. The RN signed the alternate clinical supervisor job description on 02/10/2020. Employee #8: The date of hire of the physical therapist/alternate clinical supervisor/manager was 09/21/2016. Clinical record review findings for the administrator/RN clinical manager-supervisor (employee #1): Patient #2: On January 20, 2022 at approximately 6:28 PM, review of the clinical record revealed the start of care date was 01/11/2022, the primary diagnosis is sepsis and that skilled nursing (SN) services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 01/11/2022 through 03/11/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the start of care SN visit on 01/11/2022. Review of "Client Calendar Report" documentation revealed employee #1 is scheduled to perform the recertification SN visit on 03/08/2022. Patient #4: On January 20, 2022 at approximately 7:31 PM, review of the clinical record revealed the start of care date was 01/18/2022, the primary diagnosis is chronic obstructive pulmonary (lung) disease (COPD) and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 01/18/2022 through 03/18/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the start of care SN visit on 01/18/2022. Patient #5: On January 21, 2022 at approximately 10:40 AM, review of the clinical record revealed the start of care date was 02/04/2021, the primary diagnosis is acute on chronic systolic (congestive) heart failure and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the recertification period of 12/01/2021 through 01/29/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) provided routine SN services on 12/07/2021, 12/21/2021, 12/31/2021, 01/04/2022 and 01/19/2022 (Wednesday). Review of "Client Calendar Report" documentation revealed employee #1 is scheduled to perform the recertification SN visit on 01/25/2022. Patient #6: On January 21, 2022 at approximately 11:53 AM, review of the clinical record revealed the start of care date was 06/12/2021, the primary diagnosis is Type-2 diabetes mellitus with diabetic ophthalmic (eyes) complications and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the recertification period of 12/09/2021 through 02/06/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the SN recertification visit on 12/08/2021 (Wednesday). Review of "Client Calendar Report" documentation revealed employee #1 is scheduled to perform the recertification SN visit on 02/02/2022 (Wednesday). Patient #8: On January 21, 2022 at approximately 12;26 PM, review of the clinical record revealed the start of care date was 11/27/2021, the primary diagnosis is acute ischemic (weakened muscles) heart disease and that SN services are to be provided as documented on the "Home Health Plan of Care & Certification" for the initial certification period of 11/27/2021 through 01/25/2022. SN visit note documentation revealed the administrator/clinical manager-supervisor (employee #1) performed the start of care SN visit on 11/27/2021. An interview was conducted with the administrator/clinical manager-supervisor (employee #1) and the COO (employee #10) on January 21, 2022 at approximately 3:40 PM. During the interview, the administrator/RN clinical manager-supervisor (employee #1) reported that employee #1 is providing SN services due to staffing shortages. Employee #1 reported that employee #2 was not available to function as the alternate RN to employee #1 on Wednesdays because Wednesday is employee #2's regular day off. Employee #1 and the COO confirmed there was no documentation which provided evidence that an alternate supervising was available on the above referenced dates when employee #1 was providing SN services.