Every finding on record at Patients First Home Health Agency, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 23210 S CRENSHAW BLVD, SUITE 200 TORRANCE, CA 90505 Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44916 Health Facilities Evaluator Nurse, Surveyor ID: 22303 Unduplicated Admissions - 56 Active Patients - 13 Sample Size - 7 Home Visits- 3

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) plan/drill for field staffs were completed on an annual basis. This failure had the potential to result in the staff lacking knowledge to respond effectively during an emergency/disaster situation and had the potential to result in harm to patients. On 1/29/23 at 12:30 p.m., during an interview with the Administrator, the Administrator indicated and showed that there were no emergency drills performed for office and field staff. During a concurrent record review of the in-service book for 2022, the book did not indicate there was any documented evidence that the in-services were done for the year 2022. A review of the home health agency's (HA) policy titled, "Emergency Management", revised 10/2018 indicated, the agency will test the emergency management plan at least annually, either in response to an actual emergency or in a planned exercise. Planned exercises are realistic scenarios and related to the priority emergencies defined by leadership and DO NOT INCLUDE table top drills nor are they required to be performed at patients homes. All actual responses and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical and support staff. Documentation will be used to identify deficiencies and opportunities for improvement based on all monitoring activities and observations during the exercise.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 23210 S CRENSHAW BLVD, SUITE 200 TORRANCE, CA 90505 Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor # 44916 Health Facilities Evaluator Nurse, Surveyor # 22303 Unduplicated Admissions - 56 Active Patients - 13 Sample Size - 7 Home Visits- 3

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to provide and ensure one of seven sampled patients (Patient 4) received information regarding the state toll free home health telephone hotline, its contact information, its hours of operation, and its purpose. This failure resulted in a violation of Patient 4's rights due to not having the information necessary to make a complaint regarding the agency’s care. A review of Patient 4’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 1/20/23 to 3/20/23, indicated a Start of Care date of 1/20/23, with a diagnosis include osteoarthritis (occurs when flexible tissue at the ends of bones wears down). During an observation of the home visit on 1/28/23, at 2 p.m., Patient 4 did not have the information to call the California Department of Public Health. Patient 4 was observed looking for the agency folder but an incorrect State hotline number was written in the front page of the folder. During an interview on 1/28/23, at 2:25 p.m. Patient 4 stated, “No, I do not know how to contact the state. The visiting nurse did not mention about it". A review of the HHA’s undated policy and procedure titled, “Admission Criteria and Process”, indicated patient rights and responsibilities will be explained to the patient and family/caregiver.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to conduct an accurate comprehensive assessment for one of seven sampled patients (Patient 1). This deficient practice had the potential to cause a delay in the progress of Patient 1’s delivery of the plan of care. 1. A review of Patient 1's Patient Profile indicated, a Start of Care (SOC) date of 10/25/22, with a diagnoses that included low back pain and arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age). During a review of the HHA's document titled "Home Health Certification and Plan of Care" (POC), for the re-certification period from 12/24/22 to 2/21/23, included an order for the skilled nurse (SN) to visit once a week for nine weeks for observation and assessment of all bodily systems with emphasis on musculoskeletal status for joint pain, gait and transfers, weakness; nutrition and hydration status; patient/caregiver response to the disease process and teach coping mechanisms as needed; observing universal precautions, proper disposal of wastes and supplies; compliance with diet and medications; safety measures and psycho-social adjustment. SN to instruct and teach patient and caregiver the importance of compliance with prescribed medications; new, changed drug regimen related to desired/adverse/toxic effects, contraindications dose/time and route of administration, diet; universal precautions; infection control; pain control measures; energy conservation and relaxation techniques; fall precautions; ambulation precaution; home safety and emergency protocol. On 1/28/23, a home visit was scheduled to be conducted at Patient 1's independent living with Registered Nurse 1 (RN 1) at 12:00 noon. Upon arrival to the independent living center at 11:15 a.m. and instruction was given by the HHA's administrator to wait for the RN to call the surveyor when she arrived. Caregiver knocked on the surveyor's vehicle at 11:45 a.m.to inform that the nurse was already in Patient 1's room. Upon entering the room, Patient 1 was observed sitting on his bed with a caregiver present. Registered Nurse (RN) 1 had already concluded her visit. During the home visit, Patient 1 was sitting on his bed, awake and alert with periods of forgetfulness, observed that two urinals were on the floor, one was filled three fourths full of spit and the other urinal with urine. A box was found in the middle of the room serving as a make shift table. Food and clothing were scattered on the floor. Patient 1 was also seen going outside to smoke in the patio. During a review of the HHA's document titled, "Skilled Nursing Clinical Visit Note" dated 1/4/23, 1/10/23, 1/24/23 did not indicate the patient and caregiver education with regards to smoking and proper hygiene and sanitation for patient environment. During an interview with the Director of Nursing (DON) on 1/29/23 at 12:05 p.m., DON reviewed the care plan on her computer and confirmed that patient had no plan of care for smoking and proper hygiene and sanitation for Patient 1. DON also confirmed that Patient 1's plan of care did state that the SN should instruct and educate infection control and home safety. A review of the HHA's policy titled, "Ongoing Assessments" indicated that during each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial and subsequent visits. Using the standards of care identified by the organization, the clinician will reassess the patient as appropriate for safety/home environment.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to assess the continuing need for skilled nursing services for one of seven sample patients. (Patient 5). This deficient practice resulted in unnecessary continuous home health services. A review of Patient 5's clinical record indicated a Start of Care (SOC) date of 9/17/22, with a diagnosis that included dysphagia (difficulty of swallowing food or liquids). A review of Patient 5's plan of care (POC) from 11/16/22 to 1/14/23, included an order for the skilled nurse (SN) to visit twice a week for two weeks, and once a week for seven weeks to perform assessment of all body systems and check medication compliance. The plan of care indicated to notify the physician if Patient 5's systolic blood pressure (top number) was greater than 160 millimeters of mercury (mmHg) or less than 90 mmHg, diastolic(bottom number) greater than 90 mmHg, or less than 55 mmHg, pulse rate greater than 100 beats per minute or less than 60 beats per minute and respiration rates greater than 20 breath per minute or less than 12 breath per minute or a temperature greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within the physician's established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. The Discharge Planning indicated to discharge Patient 5 when medical condition is stable and the patient no longer was in need of skilled care. A review of the comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 11/16/22, indicated Patient 5 had aching pain on the right right knee with a pain level of four (4) (mild to moderate) on a pain scale of zero (no pain) to ten (worse pain) less than daily. The comprehensive assessment also indicated medication, heat, and rest relieved the pain. A review of Patient 5's skilled nursing clinical visit notes from 11/16/22 to 1/10/23 indicated Patient 5 experienced pain at a level of 4/10 to 6/10 (moderate pain), and the pain level decreased from 0/10 to 3/10 after intervention. The patient's vital signs were within a normal range. Patient 5's Bowel movements were regulated and there were no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for skilled nursing services to continue. During an interview with the Director of Patient Care Services (DPCS) on 1/29/23, at 11 a.m., when asked why the patient was re-certified for another 60 days, she stated Patient 5 needed continuous skilled nursing service for patient teaching on her medication regimen and disease process. A review of the agency's policy titled "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to maintain an accurate, current medication profile for three of seven sampled patients (Patient 1, 2 and Patient 4). This failure had the potential to result in placing patients at risk for medication errors and adverse drug reactions. A review of Patient 1's Patient Profile indicated, a start of care (SOC) date of 10/25/22, with a diagnosis that included low back pain and arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age). During a review of the HHA's document titled "Home Health Certification and Plan of Care" (POC), for the re-certification period from 12/24/22 to 2/21/23, included an order for skilled nurse (SN) to visit once a week for nine weeks for observation and assessment of all bodily systems with emphasis on musculoskeletal status for joint pain, gait and transfers, weakness; nutrition and hydration status; patient/caregiver response to the disease process and teach coping mechanisms as needed; observing universal precautions, proper disposal of wastes and supplies; compliance with diet and medications; safety measures and psycho-social adjustment. SN to instruct and teach patient and caregiver importance of compliance with prescribed medications; new, changed drug regimen related to desired /adverse/toxic effects, contraindications dose/time and route of administration, diet; universal precautions; infection control; pain control measures; energy conservation and relaxation techniques; fall precautions; ambulation precaution; home safety and emergency protocol. On 1/28/23, a home visit was scheduled to be conducted at Patient 1's independent living with Registered Nurse 1 (RN 1) at 12:00 noon. Arrived at the independent living at 11:15 a.m. and was given instruction by the HHA's administrator to wait for the RN to call this writer when she arrived. Caregiver knocked on this writer's vehicle at 11:45 a.m.to inform that the nurse was already in Patient 1's room. Upon entering the room, Patient 1 was observed sitting on his bed with caregiver present. RN 1 had already concluded her visit. During the home visit, Patient 1 was sitting on his bed, awake and alert with periods of forgetfulness, observed that 2 urinals were on the floor, one was filled three fourths full of spit and the other one with urine. A box was found in the middle of the room serving as a make shift table. Food and clothing were scattered on the floor. Patient 1 was also seen going outside to smoke in the patio. RN 1 was asked if she checked the medication for Patient 1 and stated she did. On concurrent interview, when Patient 1 was asked to show his medication bottle, he could not find his medication bottle. Observed that his caregiver stepped in to help him look for his medications. Caregiver also stepped in to look for the agency handbook. Upon record review of Patient 1's handbook, RN did not check the patient's medication and did not sign for her visit in the agency's handbook. During the medication review during this home visit on 1/28/22 the following medication discrepancies were noted. Tylenol PM (is a combination of acetaminophen / diphenhydramine) is a combination medication used to help relieve minor aches and pains) was found in his bedside table mixed with his clothing. On Patient 1's medication profile indicated patient is taking Tylenol 500 milligram (mg-a unit of measure) every 4-6 hours for low back pain meloxicam 15 mg 1 tablet daily for pain on medication profile but there was no medication found in the patient's belongings. On concurrent interview with Patient 1's caregiver, stated he could not find this medication in the patient's belongings. 2. A review of Patient 2's Patient Profile indicated, a start of care (SOC) date of 11/7/22, with a diagnosis that included hypothyroidism ( happens when the thyroid gland doesn't make enough thyroid hormone. This condition also is called underactive thyroid) and cerebral infarction (Also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) During a review of the HHA's document titled "Home Health Certification and Plan of Care" (POC), for the re-certification period from 1/6/23 to 3/6/23, included an order for skilled nurse (SN) to visit once a week for nine weeks for observation and assessment of all bodily systems. SN to monitor vital signs and report to MD. SN to monitor cardio-pulmonary, musculoskeletal pain, integumentary, psychosocial, neuro-sensory, gastrointestinal, genitourinary and coping status. SN to assess patient and caregivers level of independence with patient personal care. SN to assess the patient and caregiver level of understanding about diseases and medication management. SN to teach patient and caregiver about disease process, disease management, medication management including side effects, potential adverse effects and infection control measures, home safety, fall/injury prevention, dietary, pain management, energy conservation, emergency management and reportable parameters to SN/MD (Medical Doctor). SN to monitor patient's progress towards goal and response to treatments. SN to monitor patient and caregiver response to treatments. SN to monitor patient and caregiver compliance with teaching. SN to notify MD of any abnormal finding. On 1/28/23, at 10:07 a.m., a home visit was conducted at Patient 2's residence with licensed vocational nurse (LVN 1) . Patient 2 was observed sitting on a chair in the living room with sister and granddaughter present in the room. LVN 1 proceeded to administer care. During a review of Patient 2's medications on 1/28/23 at 10:30 a.m. The following medication discrepancies were noted on the patients medication profile: Amlodipine 10 milligrams (mg-a unit of measure for solid medications) daily for hypertension was discontinued last 1/12/23 per discharge paperwork and was changed to Amlodipine 5 mg daily. 2 orders for Levothyroxine were noted. (Levothyroxine 75 micrograms (mcg- unit of measure for solid medications) daily and Levothyroxine 25 mcg daily for thyroid supplement) Levothyroxine 25 mcg was discontinued 1/12/23 and was changed to Levothyroxine 50 mcg 1 tablet daily before breakfast per discharge paperwork. Metoprolol 25 mg twice daily for hypertension was listed on medication profile but was discontinued on 1/12/23 per discharge paperwork. Potassium Chloride 20 milliequivalents (meq- a unit of measurement) still listed on medication profile but was discontinued on 1/12/23 per discharge paperwork. Valsartan 160 mg 1 tablet for hypertension was not listed on the medication profile. Patient 2's sister stated she has been taking since 2021. During an interview with LVN 1 on 1/28/22, stated that she should be checking the medications to ensure the medication profile is up to date and report to the agency for any changes in medications and monitor its side effects and prevent errors. During an interview with the Director of Nursing (DON) on 1/29/22 at 12:05 p.m., DON stated that the expectation for field staff is to review the patient's medications, compare with the list they have on the medical record and the medication bottles found in the patient's home. Physician should be called to confirm whether medications are to be continued or discontinued to prevent medication errors and potential side effects. A review of the HHA's undated policy and procedure titled "Identification of Medication For Administration" indicated the purpose of this policy is to provide general guidelines for the safe administration of medications in the patients home. The nurse will review the written physician's orders prior to medication administration. Nurse will not administer medication and will clarify order with physician if medication order is incomplete, illegible or unclear. A review of the HHA's undated policy and procedure titled " Medication Profile" indicated the purpose of this policy is to define the use of the medication profile in evaluating the patient's medication regimen. The policy states patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A review of Patient 4’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 1/20/23 to 3/20/23, indicated an start of care date of 1/20/23, with diagnosis including osteoarthritis (occurs when flexible tissue at the ends of bones wears down). The POC included Skilled Nurse (SN) visit twice a week for one week, once a week for eight weeks, to perform skilled observation and assessment of vital sign and all body systems and medication/dietary regimen. The SN was to teach/instruct medication, adverse reaction. On 1/28/23, at 2 p.m, a home visit was conducted at Patient 5's residence with RN 2. Patient 5 was alert and oriented, sitting on her couch at the living room. At 2:15 p.m., a review was conducted of Patient 4's current medications comparing with the medication profile provided by the agency. It was noticed, Patient 1 had an empty bottle of Trazadone 50 microgram (mgm) one tab at bedtime daily. At 2:20 p.m., during an interview with Patient 4, she stated she ran out of the Trazadone medication since 5 days ago and she had to pick up her refill tomorrow. She also stated that she was not sleeping well at night because she has not been taking her Trazadone medication. She further stated that "the visiting nurse came for a visit on 1/25/23 and early a.m. today but she was not aware that i ran out of Trazadone medication or ask me about it". A further review of Patient 4's clinical record indicated no documented evidence the visiting nurse knew that Patient 4 ran out of her Trazadone medication and to coordinate with the pharmacy for refilling her medication. On 1/29/23, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should be checking all the patient's medication bottles and ask the patient regarding their medication regime during their visits. A review of the agency's policy of "Medication Profile", indicated the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the visiting nurse failed to follow the agency's policy and procedure to notify the physician promptly regarding a patient who failed to take her trazadone medication as ordered for one out of seven patients (Patient 4). This deficient practice had the potential to place patients at a potential risk for complications that could affect their overall health status. A review of Patient 4’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 1/20/23 to 3/20/23, indicated a Start of Care date of 1/20/23, with a diagnosis that included osteoarthritis (occurs when flexible tissue at the ends of bones wears down). The POC indicated the Skilled Nurse (SN) was to visit Patient 4 twice a week for one week, once a week for eight weeks, to perform skilled observation and assessment of vital sign and all body systems and medication/dietary regimen. The SN was to teach/instruct Patient 1 regarding medications and adverse reactions. On 1/28/23, at 2 p.m., a home visit was conducted at Patient 5's residence with RN 2. Patient 5 was alert and oriented, sitting on her couch in the living room. At 2:15 p.m., a review was conducted of Patient 4's current medications compared with the medication profile provided by the agency. It was noticed, Patient 1 had an empty bottle of trazadone 50 microgram (mgm) one mg tablets which was to be administered at bedtime daily. At 2:20 p.m., during an interview with Patient 4, she stated she ran out of the trazadone medication since five days ago and had to pick up her refill tomorrow. She also stated she was not sleeping well at night because she had not been taking her trazadone medication. She further stated that "the visiting nurse came for a visit on 1/25/23 and early a.m. today but she was not aware that I ran out of trazadone medication or asked me about it". A further review of Patient 4's clinical record indicated there was no documented evidence the visiting nurse promptly notified the physician that the patient had missed taking her trazadone medications for five days straight. On 1/29/23, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should be notifying the physician if there are some changes in the patient's medication routine. A review of the agency policy titled, "Administration of Medication", indicated when there is a discrepancy in the medications, the nurse will contact the physician by telephone as soon as possible to verify the medication regimen. The nurse will instruct the patient and family in the correct medication regimen. The nurse will document all telephone conversations and instructions given to the patient and/or family in the patient clinical record.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure proper coordination of services for one of seven sampled patients. (Patient 1) This deficient practice had the potential to result in the delay of required necessary services included in the plan of care. A review of Patient 1's Patient Profile indicated, a Start of Care (SOC) date of 10/25/22, with a diagnosis that included low back pain and arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age). During a review of the HHA's document titled "Home Health Certification and Plan of Care" (POC), for the re-certification period from 12/24/22 to 2/21/23, included an order for the skilled nurse (SN) to visit Patient 1 once a week for nine weeks for observation and assessment of all bodily systems, teaching and instruction regarding diet, medications and adverse reactions. A home visit was conducted at Patient 1's independent living on 1/28/23 at 11:45 a.m., with Registered Nurse 1 and the caregiver in the patient's room. During an interview on 1/28/23 with Patient 1's caregiver, the Caregiver stated he called the HHA for assistance with more resources for his nutrition and other eligible services for food. Caregiver stated he has been given resources to call but does not know what to do with it. Caregiver stated " I have no problems with communication with the agency, I just wished they could do more because I don't know what to do with the resources they gave me." During an interview with the Director of Nursing (DON) on 1/29/22 at 12:40 p.m., the DON stated she had an order to send a social worker dated 1/24/23. On concurrent record review, there was no written communication noted in the patient's electronic medical record that the agency attempted to contact their contracted service for the social worker. A review of the HHA's undated policy titled "Coordination of Services with other Providers" indicated the purpose of this policy is to ensure the coordination of services provided by the organization and by other service providers. The case manager will be responsible for coordinating services provided to the patient by the organization, including services provided directly and through contract. The case manager will act as a liaison with other organizations or individuals also providing care to the patient to ensure effective coordination of related services.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to conduct performance improvement projects (PIP) every year. This failure had the potential to affect the quality of care provided to the patients. A request was made on 1/29/23, at 1:30 p.m., to the Administrator to review the home health agency's (HHA) performance improvement projects (PIP) derived from the data collected from the QAPI (Quality Assurance and Performance Improvement) program. On concurrent interview with the Administrator, the Administrator stated she is aware of the requirement, but they do not have any performance improvement projects. A review of the PIP/QAPI document received by the administrator was incomplete. There was no documentation in the agency's PIP of the time frame and target outcome of each stated action. A review of the undated HHA"S policy and procedure titled "Quality Assurance Plan" indicated the HHA's Quality Assurance Monitoring program goals will reflect the availability of appropriate and practical agency policies, will demonstrate the identification and evolving resolution of problems for each home care service, will reflect appropriate patient satisfaction levels with agency services and will demonstrate limited gaps or delays in patient service provision and will provide opportunities to improve continuity of care whenever possible. The Quality assurance Plan assists care providers in achieving the desired home care services quality by providing a planned and systemic approach to monitoring and evaluating the care provided.