Every finding on record at Patient Plus Homehealth Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 5/22/25. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 5/22/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey. Abbreviations: - = to w = week # = number % = percent O2 = oxygen AM = morning x = times or by SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients SOB = Shortness of breath CMS = Centers for Medicare & Medicaid Services

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interview, it was determined in 21 of 151 assessments submitted for the last 12 months, the Agency failed to submit reports timely, resulting in a warning. Findings include: 1. The Error Summary report for 5/1/24 to 5/1/25, was reviewed on 5/19/25. The report included error # -3330 for 21 of 151 (13.91 %) OASIS reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing on 5/21/25 at 10:10 AM, the Director of Nursing confirmed the above findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of the Pt. admission folder, observation during a home visit, clinical record review, and staff interview, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure the Pt./patient’s representative was informed of the services to be provided in writing, and the frequency of visits provided by each discipline. Findings include: 1. The Pt. admission folder was reviewed on 5/19/25. The folder included a booklet that included a page titled; "Visit Schedule", this page contained a section for the staff to place a check mark next to the services to be provided and enter the frequency and duration of each service. 2. A home visit was conducted on 5/21/25 at 2:00 PM with Employee #2 at the residence of Pt. #2 (SOC 11/28/24). During the home visit, the Pt. admission folder was observed, it lacked the booklet identified above, documentation of the services to be provided and the visit frequency. A home visit was conducted on 5/20/25 at 12:00 PM with the Director of Nursing at the residence of Pt. #1 (SOC 11/28/24). During the home visit, the Pt. and patient’s representative were unable to locate the Pt. admission folder. 3. The following clinical records were reviewed on 5/20/25 and 5/21/25: Pt. #1. SOC 11/28/24. Pt. #2. SOC 11/28/24. Pt. #3. SOC 11/27/24. Pt. #4. SOC 11/28/24. Pt. #5. SOC 5/11/24. Pt. #6. SOC 6/4/24. Pt. #7. SOC 9/27/24. The records lacked documentation the Pt./patient’s representative was provided in writing the services to be furnished, and the visit frequency. 4. During an interview with the Director of Nursing on 5/22/25 at 10:00 AM, the Director of Nursing stated the Agency recently received the new booklets in March 2025, and they will be distributed to new patients effective May 2025. The Agency did not admit any new Pts. in 2025. The Pts. identified above were all admitted to the Agency in 2024 and the old booklet was used. During the same interview, the Director of Nursing confirmed the Agency failed to inform the Pt./patient’s representative of services to be provided in writing, and the frequency of visits provided by each discipline.

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 a review of clinical records, and staff interviews, it was determined in 4 of 7 (Pts. #1, 6, 7, and 5) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or that the initial assessment visit was done within 48 hours of receipt of the referral. 4. Pt. #5 was admitted to home health services 5/11/24 with the diagnosis of, but not limited to, Bilateral Primary Osteoarthritis. The clinical record was reviewed on 5/20/25. The clinical record included the referral for home health services dated 4/30/24 that was faxed to the Agency on 4/30/24. The SOC assessment was completed by the SN on 5/11/24 which was 11 days after receipt of the referral. The record lacked a reason for the late SOC. 5. During interviews conducted on 5/20/25 at 3:15 PM and on 5/21/25 at 10:10 AM with the Director of Nursing and Office Manager, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited, to Other Polyosteoarthritis. The clinical record was reviewed on 5/20/25. The clinical record included the SOC assessment completed by the SN and dated 11/28/24. The referral, “Documentation of Face-to-Face Encounter” form was signed by the Nurse Practitioner and dated 10/3/24 that required the SN to provide service. During an interview with the Director of Nursing on 5/21/25 at 10:10 AM, she stated the referral was emailed to the Agency on 11/12/24. The SOC visit was conducted 16 days after receipt of the referral. The record lacked a reason for the late SOC. 2. Pt. #6 was admitted to home health services on 6/4/24 with the diagnosis of, but not limited to, Bilateral Primary Osteoarthritis. The clinical record was reviewed on 5/20/25. The clinical record included the referral for home health services that was faxed to the Agency on 5/20/24. The SOC assessment was completed by the SN on 6/4/24 which was 14 days after receipt of the referral. The record lacked a reason for the late SOC. 3. Pt. #7 was admitted to home health services on 9/27/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus. The clinical record was reviewed on 5/20/25. The clinical record included the SOC assessment completed by the SN and dated 9/27/24. As of 5/20/25, the Agency lacked a referral for the SOC conducted on 9/27/24.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews, it was determined for 4 of 7 (Pts. #3, 4, 2 and 5) clinical records reviewed, the Agency failed to ensure care and services were provided as ordered by the Physician in the POC. 3. Pt. #2 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus. The clinical record was reviewed on 5/20/25. The 11/27/24 Physician face-to-face note contained “SKILLED NURSING CARE FOR:…blood glucose check…” and the POC for the certification period of 3/28/25-5/26/25 contained perimeters that "SN to notify Physician of any significant changes...- blood sugar" and “SN to…Assess blood glucose levels regularly…” The clinical record lacked blood glucose checks on 3/26/25, 4/2/25, 4/9/25, 4/16/25, 4/30/25, and 5/7/25, and lacked Physician notification that blood glucose was not assessed by the SN. 4. Pt. #5 was admitted to home health services 5/11/24 with the diagnosis of, but not limited to, Bilateral Primary Osteoarthritis. The clinical record was reviewed on 5/20/25. The Physician face-to-face dated 4/30/24 contained “home health services: continue home health. Physical therapy under current cert.” The POC dated 5/11/24 lacked physical therapy frequency and duration. On 5/21/25 the clinical records in “therapyBOSS” were accessed and reviewed with the Director of Nursing. The record lacked physical therapy notes for the certification period 5/11/24-7/9/24. The record lacked Physician notification of the missed visits or a Physician order to discontinue physical therapy. 5. During an interview conducted on 5/20/25 from 2:30 PM to 3:45 PM with the Director of Nursing and Office Manager, and on 5/21/25 at 12:00 PM with the Director of Nursing, the Director of Nursing the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to home health services on 11/27/24 with the diagnoses of, but not limited to, Heart Failure, Unspecified and Idiopathic Pulmonary Fibrosis. The clinical record was reviewed on 5/20/25, and included the POC effective 3/27/25 which required, “Orders for Discipline and Treatments… Skilled Nurses Frequency: 1W9.” The clinical record lacked documentation of SN visits for the week of 4/27/25 to 5/3/25, and lacked Physician notification of the missed visit or a Physician order for a change in the visit frequency. The SN visit note dated 4/10/25, included a record of the patient's oxygen saturation of 88% and the SN documentation, “comments: noted increased SOB this week, requiring higher flow rate of O2 using assessments reveals worsening cackles. Pt. reports fatigue after walking short distances.” The same POC required, “Monitor respiratory status, oxygen saturation, and signs of worsening dyspnea…Assess for complications…and report any significant changes to the healthcare provider promptly.” The record lacked documentation the Physician was notified of the change in Pt. status. 2. Pt. #4 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 5/20/25, and included the POC effective 3/28/25 which required, “Orders for Discipline and Treatments…Skilled Nurses Frequency: 1W9.” The clinical record lacked documentation of SN visits for the following weeks of 3/30/25 to 4/5/25, 4/20/25 to 4/26/25 and 5/4/25 and 5/10/25. The record lacked Physician notification of the missed visits or a Physician order for a change in the visit frequency.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interview, it was determined that for 1 of 1 (Pt. #4) Pt. receiving wound treatment, the Agency failed to ensure that care and services provided were according to Physician orders. Findings include: 1. Pt. #4 was admitted for home health services on 11/28/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 5/20/25. The clinical record contained a Physician Order dated 3/11/2 which required, “1) Soak Foot (with soapy water) 15 minutes; 2) Apply Medicine (Mupiracin); 3) Apply Bandage lose on toe (3rd toe) on right 2x week for 2 weeks.” The SN Visit Notes dated 3/18/25, 3/20/25 and 3/27/25 all included the following documentation by the RN: “Wound care provided: R-foot, 3rd toenail bed appears clean with no signs and symptoms of complications and with no drainage noted and nail was removed from site by Podiatrist…on 3/7/25. SN soaked R-foot in lukewarm water for 10 minutes and remove foot and pat dry with clean towel (3rd toe pat dry with 4 x 4 gauze) and applied Bacitracin ointment and Band-aid to nail bed. Wound care completed per (Podiatrist) orders…” The wound treatment provided was not according to the orders. 2. During an interview with the Director of Nursing and the Office Manager on 5/20/25 at 2:30 PM, the Director of Nursing stated that all wound treatments be in accordance with Physician/Podiatrist orders. During the same interview, the above finding was confirmed.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews, it was determined that in 5 of 7 (Pts. #1, 6, 7, 3 and 4) clinical records reviewed, the Agency failed to complete the assessment for Pneumonia and Influenza vaccines as required. 4. Pt. #3 was admitted to home health services on 11/27/24 with the diagnosis of, but not limited to, Heart Failure, Unspecified. The clinical record was reviewed on 5/20/25 and contained the form, "Immunization and Consent Form" signed by the Pt. and the SN and dated 11/27/24. The form lacked information regarding the follow-up of the patient's Influenza and Pneumonia vaccination status. 5. Pt. #4 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 5/20/25 and contained the form, "Immunization and Consent Form" signed by the Pt. and the SN dated 11/28/24. The form lacked information of the patient's Influenza and Pneumonia vaccination status. 6. During an interview with the Director of Nursing and Office Manager on 5/20/25 at 2:45 PM and 5/21/25 at 10:10 AM, the Director of Nursing confirmed staff failed to complete the assessment for Pneumonia and Influenza vaccines as required. Findings include: 1. Pt. #1 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited, to Other Polyosteoarthritis. The clinical record was reviewed on 5/20/25. The clinical record included the “Immunization Information and Consent Form” completed by the SN. The form included the inquiry; “Are you interested in receiving the Influenza vaccine?... Pneumonia vaccine?” The SN indicated “Yes” on the form and placed a checkmark to indicate the Pt. “recently received” the flu/Influenza and Pneumonia vaccines. The form lacked the date the Pt. received the vaccines, and the SN wrote “No current vaccinations for this year has been given”. The form contained conflicting documentation regarding the need and administration of the vaccines. 2. Pt. #6 was admitted to home health services on 6/4/24 with the diagnosis of, but not limited to, Bilateral Primary Osteoarthritis. The clinical record was reviewed on 5/20/25. The clinical record included “Immunization Information and Consent Form” completed by the SN and dated 6/4/24. The SN circled “Yes” on the form to the question, “Are you interested in receiving the Influenza vaccine?” The record lacked documentation the SN referred the Pt. to their Physician, local health department or other community location, as required by the Agency’s form. 3. Pt. #7 was admitted to home health services on 9/27/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus. The clinical record was reviewed on 5/20/25. The clinical record included the undated “Immunization Information and Consent Form” completed by the SN. The SN circled “Yes” on the form to the question, “Are you interested in receiving the Influenza vaccine?” The record lacked documentation the SN referred the Pt. to their Physician, local health department or other community location.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, clinical record review and staff interviews, it was determined in in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. Findings include: 1. The Pt. admission folder was reviewed on 5/19/25. The folder lacked information identifying the name and contact information of the Clinical Manager (Director of Nursing). Pt. #1. SOC 11/28/24. Pt. #2. SOC 11/28/24. Pt. #3. SOC 11/27/24. Pt. #4. SOC 11/28/24. Pt. #5. SOC 5/11/24. Pt. #6. SOC 6/4/24. Pt. #7. SOC 9/27/24. 2. During an interview with the Director of Nursing and Office Manager on 5/20/25 at 2:30 PM, it was stated that the same admission folder is given to all Pts. at SOC and confirmed that the folder lacked contact information of the Clinical Manager.

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 a review of clinical records, and staff interviews, it was determined that in 3 of 3 (Pt. #5, 6 and 7) closed clinical records reviewed, the Agency failed to complete a discharge summary. Findings include: 1. The following closed clinical records were reviewed on 5/20/25 and 5/21/25: Pt. #5. SOC 5/11/24. Pt. #6. SOC 6/4/25. Pt. #7. SOC 9/27/24. The records lacked documentation that a discharge summary was completed. 2. During an interview with the Director of Nursing on 5/20/25 at 3:15 PM and 5/21/25 at 10:10 AM, the Director of Nursing stated the discharge assessment form includes the discharge summary. However, upon review of the discharge assessments entered into the clinical records indicated above, the assessments lacked a discharge summary. During an interview with the Director of Nursing on 5/22/25 at 10:00 AM, the Director of Nursing confirmed the Agency failed to complete a discharge summary.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined that in 6 of 7 (Pts. #1, 6, 7, 2, 3 and 4) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was legible and complete. 5. Pt. #3 was admitted to home health services on 11/27/24 with the diagnosis of, but not limited to, Heart Failure, Unspecified. The clinical record was reviewed on 5/20/25. The clinical records contained the form titled, Consent for Home Care Services and Agreement, signed and dated by the Pt. on 11/27/24 but lacked entries on the areas, “Medicare/Medicaid, Release of Information, Acknowledgement.” The record also included a form titled, “Notice of Medicare Non-Coverage.” The form was signed and dated by the Pt. on 11/27/24 but the area containing “Effective Date of Coverage your current home health services will end” was left blank. 6. Pt. #4 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 5/20/25. The clinical records contained the form titled, “Notice of Medicare Non-Coverage” which was signed by the Pt. on 11/28/24, but the areas containing “Patient Number and the Effective Date of Coverage your current home health services will end” were left blank. The record also contained the forms titled, “Financial Liability, Home Health Advance Beneficiary Notice (HHABN), Consent for Home Care Services and Agreement” which were all signed by the Pt. but the areas that are required to be filled out were left blank. 7. The Agency policy titled, “Clinical Records/Medical Record Retention” was reviewed on 5/21/25 and required, “Policy…Clinical records are legal documents containing comprehensive, accurate, and organized information… Purpose…To maintain an accurate record of the services provided by (Agency) for each patient…Clinical record shall contain: 6. All documentation must be legible…9. When a patient is discharged from care, the clinical record shall be completed (including required summary, documentation…) within 30 days…10…the proper method of error correction in the clinical record shall be: a. Draw a single line through the entry in such a way that the written information underneath may still be read. Initial and date the entry…” 8. During an interview conducted on 5/20/25 from 2:30 PM to 3:45 PM and on 5/21/25 at 10:10 AM with the Director of Nursing and Office Manager, the Director of Nursing stated that the clinical record should be accurate and complete. During the same interviews, the above findings were confirmed. 4. Pt. #2 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus. The clinical record was reviewed on 5/20/25. The clinical records contained the form titled, "Consent for Home Care Services and Agreement", signed and dated by the Pt. on 11/28/24 but lacked entries on the area, "Acknowledgement...Patient Rights and Responsibilities." The record also included a form titled, “Notice of Medicare Non-Coverage.” The form was signed and dated by the Pt. on 11/28/24 but the area containing “Effective Date of Coverage your current home health services will end” was left blank. Findings include: 1. Pt. #1 was admitted to home health services on 11/28/24 with the diagnosis of, but not limited, to Other Polyosteoarthritis. The clinical record was reviewed on 5/20/25. The clinical record included the form titled; ‘Immunization Information and Consent Form” completed by the SN. The form had a date written on the form which was written over and illegible. The form titled; “Beneficiary Elected Transfer” dated 12/10/24 was completed by the SN, lacked the name of the previous home health agency and documentation to indicate this form was faxed to the previous agency, as required by the Agency’s form. The form titled; “Consent for Home Care Services and Agreement” completed by the SN. The form contained a section pertaining to Advance Directives. The SN was required to place a check mark next to “Yes” or “No” to indicate whether the Pt. had an Advance Directive. If yes, document the person’s name and contact information. This section was left blank. The same form had a date entered on the form that was written over and illegible. The form titled; “Notice of Medicare Non-Coverage” was signed by the patient’s representative and dated 11/28/24. The form lacked the effective date that the current home health services will end, as required by the CMS form. The form titled; “Home Health Advance Beneficiary Notice (HHABN)” was signed by the patient’s representative. The SN was required to date the form and/or ensure the date entered was legible. The form contained a date that was written over and illegible. The same form required the SN to complete sections on the form to indicate the reason(s) home care services and/or items will no longer be paid by Medicare; and provide the Pt./patient’s representative the choice to either receive, refuse, or pay for the services/items, as required by the CMS form. The form was left blank. The form titled; “Patient Priority Classification” was signed by the patient’s representative and dated 11/28/24. The form lacked a priority level (1- Pts. that need uninterrupted services, 2 – Pt. care can be postponed with telephone contact, 3 – Pts. that are stable and have access to resources, or 4 – Visits can be postponed 72 hours or more with little or no adverse effects). The form was left blank. 2. Pt. #6 was admitted to home health services on 6/4/24 with the diagnosis of, but not limited to, Bilateral Primary Osteoarthritis. The clinical record was reviewed on 5/20/25. The clinical record included the SN visit note dated 10/22/24 which required the SN to assess the Pt. for pain. The SN documented the Pt. experienced “aching” pain. The SN visit note lacked the location of the pain and pain intensity (Pain intensity rating, ranges from 0 equal no pain to 10 that equal severe pain), as required by the Agency’s SN visit note. The form titled; “Notice of Medicare Non-Coverage” included the patient’s signature and dated 6/4/24. The form lacked the effective date that the current home health services will end. 3. Pt. #7 was admitted to home health services on 9/27/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus. The clinical record was reviewed on 5/20/25. The clinical record included the undated “Notice of Medicare Non-Coverage” form. The form lacked the effective date that the current home health services will end and the date this form was signed by the Pt. The form titled; “Consent for Home Care Services and Agreement” was completed by the SN and dated 9/27/24. The form contained a section to indicate whether the Pt. had an Advance Directive. This section was left blank. The undated form titled; “Home Health Advance Beneficiary Notice (HHABN)” was signed by the Pt. The form required the SN to document the reason(s) home care services and/or items will no longer be paid by Medicare; and provides the Pt./patient’s representative the choice to either receive, refuse, or pay for the services/items, as required by the CMS form. The form was left blank and lacked the date the Pt. signed the form.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: SOC= Start of Care POC= Plan of Care SN= Skilled Nurse Pt./Pts.= Patient/Patients RN = Registered Nurse HHA'S = Home Health Aide's N/A = Not Applicable

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure Pts. were advised of the extent of their financial liability for care, and/or services before care was initiated. This was found in 2 of 7 (Pts. #3, and 4) clinical records reviewed. Findings include: 1. Pt. #3. SOC 10/19/2021. Primary Diagnosis: Hereditary and Idiopathic Neuropathy, Unspecified. The clinical record was reviewed on 02/22/2022 at 2:10 PM. The record contained a form signed by the Pt. on 10/19/2021, titled “Consent for Home Care Services and Agreement.” A box on this form was checked titled “Medicaid Pending: I understand I am responsible for any liability determined by the state and will be billed for services rendered if not eligible for Medicaid.” The form lacked documentation indicating the amount of the Patient’s potential financial responsibility. The record also included a form signed by the Pt. on 10/19/2021 titled “Financial Responsibility.” A box on this form was checked that indicated “Medicare: 100% of care covered under Medicare Part A benefits. Medicare approved supplies.” This form also contained “None-covered Services and/or Supplies for Medicare: N/A.” 2. Pt. #4. SOC 07/5/2021. Primary Diagnosis: Cerebral Infarction, Unspecified. The clinical record was reviewed on 02/22/2022 at 2:35 PM. The record contained a form signed by the Pt. on 07/05/2021 titled “Consent for Home Care Services and Agreement." The form lacked the type of insurance (if any) the Pt. had, as well as documentation indicating the amount of the Patient’s potential financial responsibility. 3. The Agency policy titled “Patient’s Rights” was reviewed on 02/23/2022 at 11:30 AM. The policy required: “…You have the right to…Be fully informed orally and in writing in advance of coming under the care of an agency: a. All items and services furnished by or under all arrangements with the Agency for which payment may be expected under Medicare/Medicaid or any other Federal Program of which the Agency is reasonably aware. b. Any charges for items and services not covered under Medicare. c. Any charges the individual may have to pay regarding care items and services furnished by or under arrangements with the Agency…” 4. During an interview with the Administrator and Director of Nursing on 02/23/2022 at 2:55 PM, the Director of Nursing stated Pts. should be notified of their potential financial responsibility at the SOC by the RN, and this should be documented in the Patient’s clinical record.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: A. Based on clinical records review and staff interviews it was determined the Agency failed to document the patient and/or representative were notified of the Agency's transfer and discharge policy. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. Clinical records were reviewed for Pts. #1, 2, 3, 4, 5, 6, and 7 beginning at 1:00 PM on 02/22/2022 through 2:00 PM on 02/23/2022. Pt. #1 SOC 02/18/2022 Pt. #2 SOC 11/23/2021 Pt. #3 SOC 10/19/2021 Pt. #4 SOC 07/05/2021 Pt. #5 SOC 07/18/2021 Pt. #6 SOC 08/26/2021 Pt. #7 SOC 09/14/2021 The clinical records lacked documentation that the patient and/or representative were informed of the Agency's policy on transfers and discharge. 2. During interviews with the Administrator and Director of Nursing on 02/23/2021 at 2:55 PM and on 02/24/2022 at 10:30 AM, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on clinical records review, staff interviews and policy review, it was determined the Agency failed to ensure that clinical record documents were complete and appropriately authenticated. This was found in 4 out of 7 (Pts. # 7, 3, 5 and 6) clinical records reviewed. 2. Pt. #3. SOC 10/19/21. Primary Diagnosis: Hereditary and Idiopathic Neuropathy, Unspecified. The clinical record was reviewed on 2/22/22 at 2:10 PM. The record included a form titled “Employee Visit List.” This form contained sections for entries of: the employee’s name, position, and signature; patient name; visit type; date, time in, time out, and comments related to employee visits. These sections were all left blank, yet the form was signed by the Pt. on five separate lines. 3. Pt. #5. SOC 7/18/21. Primary Diagnosis: Paraplegia, Unspecified. The clinical record was reviewed on 2/22/22 at 3:00 PM. The record included a SN visit noted dated 2/1/22. This note lacked the signature of the SN. 4. Pt. #6. SOC 8/26/21. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 2/23/22 at 10:15 AM. The record included the Start of Care Comprehensive assessment, completed on 8/26/21. This assessment was not signed or dated by the SN. The record also contained the SN visit note dated 9/2/21, which lacked the SN’s signature. The record also included the SN visit note dated 9/9/21, which lacked the SN’s signature. 5. The Agency policy titled “Clinical Records/Medical Record Retention” was reviewed on 2/23/24 at 2:30 PM. The policy required: “Clinical Record shall contain…r. Signed and dated clinical and progress notes of Nurses, HHA’s, Therapists, and Social Workers for each contact that is written the day of service and incorporated into the Patient’s clinical record at least weekly…” 6. During interviews with the Administrator and Director of Nursing on 2/23/22 at 2:55 PM, and on 2/24/22 at 10:30 AM, the above findings were confirmed. 1. Pt. # 7 SOC 09/14/2021 Primary Diagnosis: Transient Cerebral Ischemic Attack The Clinical record was reviewed on 02/23/2021 at 1:30 PM. The clinical record included a document titled, "Notice of Medicare Non- Coverage." The document was signed by Pt. #7 and dated 10/14/2021. The form was incomplete. The form lacked the date in which the coverage from the Agency would end.