Every finding on record at Pec Healthcare

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN; 39539, HFEN; and 39796, HFEN. The survey team entered the HHA on 3/20/23 at 1030 hours. The survey team reviewed nine active and four closed clinical records. The agency was in substantial compliance with the requirements for Emergency Preparedness.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN; 39539, HFEN; and 39796, HFEN. The survey team entered the HHA on 3/20/23 at 1030 hours. The survey team reviewed nine active and four closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: BID: twice a day BS: Blood sugar cc: cubic centimeter(s) CDC: Centers for Disease Control and Prevention CEO: Chief Executive Officer CHHA: Certified Home Health Aide COPD: Chronic Obstructive Pulmonary Disease (a disease that blocks airflow from the lungs) COVID 19: an infectious disease caused by the SARS-CoV-2 virus CNS: Central nervous system dl: deciliter(s) DNP: Doctor of Nursing Practice DPCS: Director of Patient Care Services Foley catheter: a tube that passes through the urethra and into the bladder to drain urine gm: gram(s) HR: Human Resources HS: at bedtime IDT: Interdisciplinary Team IV: intravenous IVP: intravenous push LVN: Licensed Vocational Nurse mg: milligram(s) ml: milliliter(s) NS: normal saline Port-a-cath: a surgically implanted central venous catheter to allows for the administration of IV medications P&P: policy and procedure PCG: Patient Care Giver PICC: Peripherally Inserted Central Catheter (A long, thin tube that goes into the body through a vein in the upper arm. The PICC helps carry nutrients and medicines into the body. It is also used to draw blood when the need to have blood tests) PO: by mouth POC: Plan of Care PRN: As needed Q: Every QAPI: Quality Assurance and Performance Improvement QA: Quality Assurance QI: Quality Improvement QD: Every day RN: Registered Nurse SC: subcutaneous SN: Skilled Nurse SOC: Start of Care TID: three times a day U: unit(s) W: week

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the complaint was thoroughly investigated for one nonsampled patient (Patient A). In addition, the process for complaint grievance were not completed as per the agency's P&P for two sampled patients (Patients A and B), creating the risk not providing quality of care and services to these patients. Findings: The agency's P&P Complaint/Grievance Process dated 11/2017 showed the patient/caregiver will be notified in writing of the result of the review or investigation within 14 days regardless of the outcome; whether the issue is resolved or unresolved or patient/caregiver is satisfied or not satisfied. The P&P also showed the Human Resource Supervisor or designee will investigate the complaint. The investigation will be informal but thorough, affording all interested persons and representatives an opportunity to submit evidence relevant to the complaint. The Human Resource Supervisor shall submit to the company administrator or President/CEO of all findings. Review of the agency's complaint log showed the following: a. Review of the agency’s QA QI Occurrence Documentation dated 12/29/22, showed the HR received an email from Patient A. Documentation showed the patient stated the SN smelled cannabis and seemed “pretty out of it and high” on the visit. The SN was struggling getting the tape on the gauze. Documentation showed the HR forwarded the email to the Administrator. The Administrator called the patient and assured that the complaint would be documented and address with the SN. However, there was no documented evidence of the interview conducted with the SN and other patients who were under the SN’s care, if any. There was also no documented evidence on what the outcome of the investigation was. In addition, there was no documented evidence the patient/caregiver was notified in writing of the result of the review or investigation within 14 days regardless of the outcome; whether the issue was resolved or unresolved or patient/caregiver was satisfied or not satisfied as per the agency's P&P. b. Review of the agency’s QA QI Occurrence Documentation dated 5/18/19, showed the agency's staff received a call from the physician’s office that the agency could not do a job and the patient (Patient B) went to the hospital. Documentation showed the event was traced back. The SN called the physician’s office to apologize and the agency staff would do marketing follow-up visit. However, there was no documented evidence the physician’s office was notified in writing of the result of the review or investigation within 14 days regardless of the outcome; whether the issue was resolved or unresolved or patient/caregiver was satisfied or not satisfied. On 3/29/23 at 1100 hours, an interview and concurrent record review was conducted with the Administrator. She was informed and acknowledged the findings.

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 agency failed to ensure the medication profiles were updated to reflect the current medications to include the specific indications and parameters for their use, and include all side effects, actual or potential drug interactions, and duplicate drug therapy for six of 13 sampled patients (Patients 3, 5, 7, 8, 10, and 13). This failure created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. 4. Review of Patient 5's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 4/11/22. The patient was certified for home health services during the certification period from 2/5/23 to 4/5/23. The Medication Profile , for the certification period from 2/5/23 to 4/5/23, showed the patient’s medications included SITagliptin phosphate (antidiabetic) 100 mg one tablet PO QD, atorvastatin calcium (antilipemic) 40 mg one tablet PO QHS, empagliflozin (antidiabetic) 10 mg one tablet PO QD, glargine (insulin) 40 u SC Q morning and 46 u SC Q HS, losartan potassium (antihypertensive) 50 mg PO QD. A joint home visit with LVN 1 was conducted on 3/23/23 at 1100 hours, to Patient 5's home. Review of the patient’s medications showed the patient was on glargine (insulin) 40 u SC QHS instead of 46 u Q HS. The patient stated she was on ferrous sulfate (supplement) 326 mg two to three times a day, glipizide (antidiabetic) 5 mg PO QD, folic acid (supplement) 1 mg PO QD, and lispro (insulin) 10 u PRN if BS more than 200 mg/dl, which were not listed in the medication profile. Further review of the clinical record failed to show documented evidence for the review of the medications for any potential drug interactions. For example, the patient had two antidiabetic medications (SITagliptin phosphate and empagliflozin) and insulin (glargine). According to Lexi-Comp's pharmacology website, the potential interactions for empagliflozin is that antidiabetic agents may enhance the hypoglycemic effect of hypoglycemia-associated agents. However, there was no documented evidence the agency had identified the potential drug interactions between the antidiabetic agents. On 3/29/23 at 841 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 5. Review of Patient 8's clinical record was initiated on 3/22/23. The clinical record showed the SOC was 6/24/22. The patient was certified for home health services during the certification period from 12/21/22 to 2/18/23 and 2/19/23 to 4/19/23. The Medication Profile, for the certification 2/19/23 to 4/19/23, showed the patient’s medication included Xarelto (anticoagulant) 20 mg one tablet PO QD. According to Lexi-Comp's pharmacology website, the significant adverse reaction for Xarelto include major hemorrhage. However, there was no documented evidence the agency had identified the significant adverse reaction to this medication. On 3/29/23 at 0905 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 6. Review of Patient 13's closed clinical record was initiated on 3/22/23. The clinical record showed the SOC was 5/25/22. The patient was certified for home health services during the certification period from 5/25/22 to 7/23/22. The Medication Profile, for the certification 5/25/22 to 7/23/22, showed the patient’s medications included lisinopril (antihypertensive) 5 mg one tablet PO QD, glargine (insulin) 5 units BID, lispro (insulin) 2 units before meal, albuterol sulfate (used for COPD) one puff Q six hours PRN for SOB/wheezing, aspirin (non-steroidal anti-inflammatory drug) 81 mg PO QD, diclofenac sodium (non-steroidal anti-inflammatory drug) 1% apply to affected area left leg Q six hours PRN, colace (laxative) 250 mg one tablet PO BID, gabapentin (antiseizure) 600 mg one tablet TID, loratadine (used for allergic rhinitis) 10 mg one capsule PO QD, lurasidone hcl (antipsychotic) 20 mg one tablet PO QD, methocarbamol (muscle relaxant) 750 mg one tablet Q six hours, oxycodone ER (opioid analgesic)15 mg one tablet Q four hours PRN for moderate to severe pain, polyethylene glycol (laxative) 17 gram PO QD PRN for constipation, sennosides (laxative) 8.6 mg two tablets BID, sertraline (antidepressanT)100 mg one tablet PO QD, daptomycin (antibiotic) 420 mg/23 ml IVP over two to three minutes Q 24 hours IVP via PICC, ceftriaxone (antibiotic) 2 gm IV Q 24 hours via pump over 30 minutes, sodium chloride 10 ml flush before and after IV infusion, heparin sodium (anticoagulant) lock flush 100 u/ml 5 ml flush after the last normal saline flush. According to Lexi-Comp's pharmacology website, the potential drug interaction of methocarbamol with oxycodone is CNS Depressants may enhance the CNS depressant effect of oxycodone. Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. However, there was no documented evidence the agency had identified the potential drug interaction for these medications. On 3/29/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2 a. Review of Patient 10's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 5/2/19. The patient was certified for home health services during the certification period from 12/12/22 to 2/9/23 and 2/10/23 to 4/10/23. The Medication profile for the certification period from 12/12/22 to 2/9/23 and 2/10/23 to 4/10/23 showed the patient's medications included carisoprodol (muscle relaxant) 350 mg one tablet PO four times a day, hydromorphone hcl (opiate) 4 mg tablet one tablet PO Q4hrs PRN for moderate to severe pain, celexocib (cyclooxygenase 2 inhibitors 200 mg one capsule BID, alprazolam (benzodiazepines) 0.5 mg one tablet QHS, hydrocodone-acetaminophen (analgesics-antipyretics) 10/325 mg two tablets Q3H PRN for moderate to severe pain and quetapine fumarate (antimanic) 400 mg one tablet TID and two tablets QHS. However, review of the clinical record failed to show documented evidence as to which medication needed to give first to address the patients moderate pain level. b. Based on the Lexicomp Drug interactions for Hydromorphone showed, may enhance the CNS depressant effect of Opioid Agonists. Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. Review of the Medication Profile for the certification period from 12/12/22 to 2/9/23 and 2/10/23 to 4/10/23, showed a section for Drug Regimen Review. However, the RN failed to show documented evidence of the Drug Regimen Review was performed between hydromorphone hcl (opiate) 4 mg tablet and alprazolam (benzodiazepines) 0.5 mg to identify the potential drug reactions as the sections were left blank. On 3/29/23 at 0935 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was asked as to which medication needed to give for moderate pain. The RN QA stated, The RN QA replied, hydrocodone-acetaminophen (Norco) should be for moderate pain and hydromorphone hcl (Dilaudid) for severe pain. She further stated, the indication should be specific for the type of pain. The RN QA was further asked if the potential drug reactions for hydromorphone hcl (opiates) and Alprazolam (benzodiazepines) as CNS depressants were identified. The RN QA stated, I have not enforced it. She was informed and acknowledged the findings. Review of the agency’s P&P titled Medication Profile dated 5/1/2002, showed patients receiving medications will have a current, accurate medication profile in the clinical record. 1. Review of Patient 3's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 12/15/22. The patient was certified for home health services during the period from 12/15/22 to 2/12/23. The Medication Profile for the certification period from 12/15/22 to 2/12/23, showed the patient’s medications included levalbuterol (bronchodilator) three cc inhalation PRN, Breo Ellipta (used to treat asthma or COPD) one puff inhalation PRN, Voltaren (nonsteroidal anti-inflammatory drug) one external application PRN, and triamcinolone (corticosteroid) one external application PRN. There was no documented evidence in the medication profile showing the specific indications for the PRN medications. On 3/29/23 at 0946 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the findings. 2. Review of Patient 7's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 12/3/21. The patient was certified for home health services during the period from 1/27/23 to 3/27/23. On 3/23/23 at 1050 hours, a joint home visit was conducted with RN 1 to Patient 7’s home. Review of the patient’s medications with RN 1 showed the patient was taking hydrocodone-acetaminophen (opioid) 5/325 mg one tablet PRN TID for breakthrough pain instead of BID as written in the medication profile. The medication profile also showed the patient was taking Xeloda (used to treat certain types of cancer) 500 mg three tablets PO BID for 14 days then seven days off, every 21 days. However, the PCG stated the patient was not taking the medication anymore. On 3/23/23 at 1116 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 verified the medication profile was not updated to reflect the patient’s current medications.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the updated comprehensive assessment was completed within 48 hours of the patient's return to home from the hospital for one of 13 sampled patients (Patient 13), creating the risk of not providing necessary care and services timely to meet the care needs for this patient. Findings: Review of Patient 13's closed clinical record was initiated on 3/22/23. The clinical record showed the SOC was 5/25/22. The patient was certified for home health services during the certification period from 5/25/22 to 7/23/22. Further review of the clinical record showed the patient was transferred to the acute care hospital on 6/10/22. The Resumption of Care Comprehensive Adult Assessment dated 6/15/22, showed the patient was recently “inpatient hospital due to high blood sugar.” However, the SN’s assessments for the patient’s bowel and external genitalia were not completed. On 3/29/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POC included specific information related to the indication for the PRN discipline visits and the use of the compression stockings for three of 13 sampled patients (Patients 2, 3, and 8). This failure created the risk of not providing necessary services for these patients. 3. Review of Patient 8's clinical record was initiated on 3/22/23. The clinical record showed the SOC was 6/24/22. The patient was certified for home health services during the certification period from 12/21/22 to 2/18/23 and 2/19/23 to 4/19/23. The POC for the certification period, from 2/19/23 to 4/19/23, showed to assess and/or perform and/or instruct patient and/or PCG application of compression dressing/stockings. The SN note dated 2/20,23, showed the RN instructed the patient “wears” compression stockings to bilateral lower extremities (thigh high with open toe), 12 hours on and 12 hours off. * However, the POC failed to show documented evidence as to the information on how long the compression stockings will be worn by the patient. On 3/29/23 at 0905 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 1. Review of Patient 2's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 1/31/23. The patient was certified for home health services during the period from 1/31/23 to 3/31/23. Review of the Physician Orders dated 1/30/23, cited SN visits 4W1 and one PRN. However, there was no documented evidence showing the specific indication for the PRN SN visit. On 3/29/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the finding. 2. Review of Patient 3's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 12/15/22. The patient was certified for home health services during the period from 2/13/23 to 4/13/23. Review of the Physician Orders dated 2/13/23, cited SN visits 3W9 and one PRN. However, there was no documented evidence showing the specific indication for the PRN SN visit. On 3/29/23 at 0946 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the finding.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the verbal orders were dated by the physician for one of 13 sampled patients (Patient 13), creating the risk of not providing appropriate, consistent, and quality care to the patient. Findings: According to the California Code of Regulations, Title 22, Section 74701(a), no medication or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient's attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice within 30 working days. The agency's P&P titled Physician Participation in Plan of Care dated 5/2022 showed the attending physician will certify the need for home health care services by signing the plan of care/treatment within 30 days of the start of care. Review of Patient 13's closed clinical record was initiated on 3/22/23. The clinical record showed the SOC was 5/25/22. The patient was certified for home health services during the certification period from 5/25/22 to 7/23/22. The POC, for the certification period from 5/25/22 to 7/23/22, showed the RN obtained the verbal SOC on 6/8/22. The document showed a section for the physician’s signature and date when signed. However, there was no documented evidence when the POC was signed by the physician. The Physician Order dated 5/25/22, showed SN visits daily times three, 1W3, and 2 PRN visits for PICC complication/removal. The order included SN evaluation with IV therapy and SN to assess all systems, medication, regimen/compliance, diet, nutrition, psyche, social, and home safety. The Physician Order dated 6/15/22, showed SN visit 1W3 and 2 PRN visits for IV removal or complications. The order included SN to continue IV infusion. Both physician's orders showed a physician’s signature; however, there were no dates when the Physician Orders were signed. On 3/29/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the coordination of care related to the patient’s refusal of treatment for one of 13 sampled patients (Patient 3). This failure created the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 3's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 12/15/22. The patient was certified for home health services during the period from 12/15/22 to 2/12/23. Review of the Aide/Homemaker Care Plan dated 12/19/22, showed to assess the patient’s vital signs including the temperature, blood pressure, pulse, and respirations during the visits. Review of the CHHA’s Progress Notes dated 12/19, 12/21, 12/23, 12/27, 12/29, 12/30/22, 1/3, 1/4, 1/6, 1/9, 1/12, 1/16, 1/18, and 1/19/23, showed the CHHA visited the patient’s home during these dates and documented the patient refused to have his blood pressures, pulses, and respirations checked. Further review of the clinical record showed no documented evidence the CHHA had reported the patient’s numerous refusals of vital signs to be taken during the visits to the RN. On 3/29/23 at 1005 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to coordinate the care to meet the patients' care needs for two of 13 sampled patients (Patients 5 and 9), creating the risk of not providing the necessary care and services to these patients. 2. Review of Patient 5's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 4/11/22. The patient was certified for home health services during the certification period from 2/5/23 to 4/5/23. The Physician Orders dated 3/2/23, showed SN visit daily. The interventions included wound care to the right great toe and right plantar foot with NS, apply ColActive plus AG (wound dressing), cover with dry dressing, wrap with Kerlix and ace wrap, and secure with tape daily and PRN if dislodged. The SN note dated 3/3, and 3/6/23, showed the right great toe “area dry no drainage”. The SN note dated 3/7, 3/8, 3/13, and 3/16/23, showed the right great toe “wound area dry, no drainage”, and no treatment needed. Documentation showed wound care to right plantar foot and right great toe, no treatment needed at this time. The Wound Care Flow Sheet dated 3/6 and 3/13/23, showed the right great toe was dry. Documentation showed no treatment needed. The SN noted dated 3/20/23, showed no treatment for right great toe. A joint home visit with LVN 1 was conducted on 3/23/23 at 1100 hours, to Patient 5's home. LVN 1 performed wound care to patient’s right plantar foot. LVN 1 stated the patient’s right great toe wound was closed. LVN 1 stated the RN Case Manager told her to cover the patient’s right great toe for protection. However, there was no documented evidence the SN coordinated with the physician regarding the status of the right great toe to update the patient’s POC. On 3/29/23 at 841 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. The agency's P&P titled Care Coordination dated 5/2/02, showed the purpose was to ensure the coordination of services for each patient. the policy showed timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient and relevant to the care/service provided. The primary clinician will be responsible for facilitating communication about changes in the patient's status between assigned personnel. Review of Patient 9's closed clinical record was initiated on 3/23/23. The clinical record showed the SOC was 2/22/23. The patient was certified for home health services during the certification period from 2/22/23 to 4/22/23. The POC, for the certification period from 2/22/23 to 4/22/23, cited RN/LVN BID x 1, Daily x 2, starting 3/12/23 every 3 weeks daily x 3 and 3 PRN for IV complications. The POC also showed SN to assess all body system. Review of the OASIS SOC dated 2/22/23, showed the RN had performed initial comprehensive assessment. The assessment includes the cardiovascular system. The cardiovascular system was assessed to be within normal limits. In addition, review of the OASIS ROC dated 3/10/23, showed the RN had performed initial comprehensive assessment. The assessment includes the cardiovascular system. The cardiovascular system was assessed to be within normal limits. Review of the SN visit notes dated 3/22/23 showed the SN had performed the body system assessment. The assessment included cardiovascular system. The patient was assessed to have a bilateral lower extremity edema "little bit". Further review of the SN visit notes dated 3/23/23 showed the patient was assessed to have a bilateral lower extremity edema "little bit". SN instructed to elevate the bilateral lower extremity to promote circulation. However, review of the clinical records failed to show documented evidenced of the physician was notified of the bilateral lower extremity edema. On 3/29/23 at 1022 hours an interview with clinical record review was conducted with the RN QA. The RN QA was asked if the physician was notified of the bilateral lower extremity edema. The RN QA checked the section on the visit note for the coordination of care. The RNQA replied, there was no documentation of the notification. The RN QA was further asked if it was a change in the patient condition. The RN QA replied, yes, it was a change. She was informed and acknowledged the findings.

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 observation, interview, and clinical record review, the agency failed to provide the written instructions outlining the visit schedules for three of 13 sampled patients (Patients 5, 6, and 7). This failure created the risk of not providing the necessary information to these patients. 3. Review of Patient 5's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 4/11/22. The patient was certified for home health services during the certification period from 2/5/23 to 4/5/23. A joint home visit with LVN 1 was conducted on 3/23/23 at 1100 hours, to Patient 5's home. Review of the patient's home folder provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 3/29/23 at 841 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 1. Review of Patient 6's clinical record was initiated on 3/22/23. The clinical record showed the SOC was 1/19/21. The patient was certified for home health services during the certification period from 3/10/23 to 5/8/23. The POC, for the certification period from 3/10/23 to 5/8/23, cited one SN visit every other week and two PRN visits for Foley catheter complications and CHHA visits 1W1, 3W8, and 1W1. On 3/23/23 at 0800 hours, a joint home visit was conducted with CHHA 1 to Patient 6’s home. CHHA 1 was asked to show the written instructions outlining the CHHA visit schedule. CHHA 1 showed the calendar; however, it was blank. CHHA 1 verified she only called the patient to confirm the appointment date and time and did not provide a visit calendar schedule. Further review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedules. On 3/23/23 at 0915 hours, an interview and concurrent record review was conducted with CHHA 1. CHHA 1 was informed and acknowledged the finding. 2. Review of Patient 7's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 12/3/21. The patient was certified for home health services during the period from 1/27/23 to 3/27/23. The POC, for the certification period from 1/27/23 to 3/27/23, cited one SN visit every two months and two PRN visits. On 3/23/23 at 1050 hours, a joint home visit was conducted with RN 1 to Patient 7’s home. RN 1 was asked to show the written instructions outlining the RN visit schedule. RN 1 showed the calendar; however, it was blank. The PCG was asked if the agency provided visit calendars to the patient. The PCG replied no and that the agency only called. Further review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedules. On 3/23/23 at 1116 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

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 interview and clinical record review, the agency failed to provide the name and contact information of the clinical manager for two of 13 sampled patients (Patients 5 and 6). This failure created the risk of not providing the necessary information to these patients. 2. Review of Patient 5's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 4/11/22. The patient was certified for home health services during the certification period from 2/5/23 to 4/5/23. A joint home visit with LVN 1 was conducted on 3/23/23 at 1100 hours, to Patient 5's home. Review of the patient's home folder provided by the HHA showed no documented evidence of the written instruction outlining name of the HHA’s clinical manager. On 3/29/23 at 841 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 1. Review of Patient 6's clinical record was initiated on 3/22/23. The clinical record showed the SOC was 1/19/21. The patient was certified for home health services during the certification period from 3/10/23 to 5/8/23. The POC, for the certification period from 3/10/23 to 5/8/23, cited one SN visit every other week and two PRN visits for Foley catheter complications. On 3/23/23 at 0800 hours, a joint home visit was conducted with CHHA 1 to Patient 6’s home. Review of the patient's admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA's clinical manager. On 3/23/23 at 0915 hours, an interview and concurrent clinical record review was conducted with CHHA 1. CHHA 1 was informed and acknowledged the finding.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to measure, analyze, and track quality indicators to assess the processes of care as part of the QAPI program. The agency also failed to ensure the required members of the QAPI committee were in attendance during the QAPI meetings as per the P&P. These failures created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. a. Review of the agency’s QAPI program and meeting minutes for the years 2020 and 2021 was initiated on 3/27/23 at 1026 hours. Review of the QAPI Binder, showed the agency performed QA/Performance Improvement 2020. The binder includes the Occurrence Report. The Occurrence Report includes Infection control, Covid 19. Review of the Occurrence Report graph showed the total number of occurrence for Covid 19 was 30. Review of the COVID for 2020 showed the total number of positive cases were 7 (5 patients and 2 staffs). However, review of the agency document failed to show documented evidence of the tracking and trending of the infection control program guarterly. In addition, there were no identifiable measures on how the committee analyzed the collected data that were identified. b. Review of the QAPI Binder, showed the agency performed QA/Performance Improvement 2021. The binder includes the Occurrence Report. The Occurrence Report includes Infection control, Covid 19. Review of the Occurrence Report 2021 graph showed the total number of occurrence for Covid 19 was 20. Review of the COVID for 2020 showed the total number of positive cases were 8 (2 patients and 6 staffs). However, review of the agency document failed to show documented evidence of the tracking and trending of the infection control program guarterly. In addition, there were no identifiable measures on how the committee analyzed the data that were identified. On 3/28/23 at 1400 hours, an interview with concurrent clinical record review was conducted with the Administrator was asked as to how they can they trend and track the Covid cases. The Administrator stated, it was done annually, not quarterly. The Administrator was also asked as to the measures on how they track the Covid cases. She replied, we based it on the details that was documented on the infection control logbook. On 3/29/23 at 1043 hours, a follow -up interview with concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. Review of the agency’s P&P titled Quality Assurance and Performance Improvement – QAPI – Program dated 3/1/2012, showed the CEO/Administrator and/or the Director of Nursing, Quality Assurance Nurse, Medical Director, and applicable team members will be included in the QAPI committee. The QAPI committee will meet on a quarterly basis to discuss activities and outcomes. XX. Review of the agency’s QAPI program and meeting minutes for the years 2019 to 2022 was initiated on 3/28/23. The QAPI program showed the committee met quarterly and as needed. However, review of the Home Health Sign-in Sheet for the years 2019, 2020, and 2021 showed no documented evidence the Medical Director attended the QAPI meetings as required per the P&P. In addition, review of the 2022 QAPI Meeting Agenda and Minutes showed the Medical Director attended the first quarterly meeting on 4/7/22; however, there was no documented evidence showing the Medical Director attended the second and third quarterly meetings. On 3/29/23 at 0955 hours, an interview and concurrent record review was conducted with the Administrator. The Administrator was informed and verified the Medical Director did not attend the QAPI meetings regularly. XX. Review of the agency’s P&P titled Quality Assurance and Performance Improvement – QAPI – Program dated 3/1/2012, showed the agency will accomplish QAPI review work performed by department supervisors. All departments and services will be involved in QAPI activities and the organization's efforts to continuously improve services. The organization will systematically analyze underlying causes of systematic problems and adverse events. Review of the agency’s QAPI program and meeting minutes for the years 2019 and 2022 was initiated on 3/28/23. The QAPI program showed the agency had developed and maintained an ongoing data-driven QAPI program. Review of the QAPI program for the years 2019 and 2022 showed the agency had collected, tracked, and trended the data identified as part of the performance improvement projects. However, there was no documented evidence showing the QAPI committee had analyzed the data collected. In addition, there was no documented evidence showing the infection control data for 2019 and 2022 was discussed and analyzed during the QAPI meetings. On 3/29/23 at 0955 hours, an interview and concurrent record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to maintain an infection control program related to the use of hand hygiene and the use of a medical equipment for one of 13 sampled patients (Patient 5), creating the risk of the spread of infection. Findings: According to CDC, the Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient’s immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal The agency's P&P titled Nursing Bag Techniques dated 5/02 showed the principles in bag technique have been developed and will be utilized to maximize the efficient use of the bag and to assure asepsis and the control of infection. Unused or cleaned equipment will be kept in the bag. Contaminated materials will be double bagged and transported separately. When visit is completed, reusable equipment will be cleaned using alcohol/soap and water as appropriate, hands will be washed, and equipment and supplies will be returned to the bag. For stethoscope, bell and diaphragm – alcohol. Review of Patient 5's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 4/11/22. The patient was certified for home health services during the certification period from 2/5/23 to 4/5/23. The Physician Order dated 3/2/23, showed SN visit daily. The interventions included to provide wound care to the right great toe and right plantar foot with NS, apply ColActive plus AG (wound dressing), cover with a dry dressing, wrap with Kerlix and ace wrap, and secure with tape daily and PRN if dislodged. A joint home visit with LVN 1 was conducted on 3/23/23 at 1100 hours, to Patient 5's home. The following was observed: - LVN 1 auscultated the patient’s lungs and chest using a stethoscope. LVN 1 returned the stethoscope to the nursing bag without cleaning which was not consistent as per the agency’s P&P. - LVN donned gloves. LVN 1 removed the wound dressing from the patient right lower extremity. LVN doffed her gloves without performing hand hygiene, then donned new gloves. LVN 1 performed treatment to the patient’s right plantar foot. LVN doffed her gloves without performing hand hygiene. On 3/23/23 at 1150 hours, an interview was conducted with LVN 1. She stated the stethoscope was placed inside a plastic bag which was in the nursing bag. LVN 1 was informed of the above observation and the findings. On 3/29/23 at 841 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.

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 interview and record review, the agency failed to ensure the infection control data was analyzed and evaluated to monitor the effectiveness of the agency’s infection control program. This failure created the risk of not identifying the appropriate action plans for infection control program. Findings: Review of the agency’s P&P titled Infections/Exposure Control Plan dated 5/1/02, showed the infection control plan will be monitored and evaluated in the annual program evaluation. Infection control data will be collected, as identified in the following policies, analyzed, and trended. Information obtained will be given to the designated IDT/QI Committee and used to improve patient/client care as well as, improve the agency’s performance in the implementation of its infection/exposure control plan. Review of the agency’s infection control program for 2019 and 2021 was conducted on 3/28/23. The infection control program for 2019 and 2021 showed the agency had collected, tracked, and trended the infection occurrences for both patients and staff. However, further review of the infection control program showed no documented evidence the agency had analyzed the data and evaluated their action plans to ensure its effectiveness. On 3/28/23 at 1316 hours, an interview and concurrent record review was conducted with the Administrator. The Administrator was asked about the agency’s infection control program. The Administrator stated the infection control committee members included the Administrator, QA RNs, DPCS, and the HR Coordinator. The committee met quarterly and as needed in conjunction with the QAPI meetings. When asked how the committee analyzed and evaluated their infection control program, the Administrator stated they would review the data collected and discussed the patterns and trends during the meetings. Review of the QAPI Meeting Agenda and Minutes for 2019, 2021, and 2022 showed no documented evidence of a meaningful analysis and evaluation of the infection control program. On 3/29/23 at 0955 hours, a follow-up interview and concurrent record review was conducted with the Administrator. The Administrator was informed of the findings. The Administrator verified they only verbally discussed the infection control data but did not document what were discussed.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the care and services were provided in accordance with the POC for three of 13 sampled patients (Patients 7, 10, and 13). This failure created the risk of not providing the appropriate, consistent, and quality care to these patients. 3. Review of Patient 13's closed clinical record was initiated on 3/22/23. The clinical record showed the SOC was 5/25/22. The patient was certified for home health services during the certification period from 5/25/22 to 7/23/22. The SOC Comprehensive Adult Assessment dated 5/25/22, showed the SN instructed the patient to keep right upper arm PICC dressing clean and dry, and to notify the physician/SN if the site was red, swollen and “drainage.” The POC for the certification period, from 5/25/22 to 7/23/22, showed SN to cleanse right upper arm insertion site PICC with alcohol swabs X3 then with chlorhexidine (antiseptic) swab , apply Biopatch (anti-infective dressing) and cover with SorbaView (central line dressing) dressing weekly to maintaining sterile technique. The POC showed to change injection caps weekly, after blood draws and PRN leaking or obstruction. Further review of the document showed the patient was transferred to the hospital on 6/10/22. The Resumption of Care Comprehensive Adult Assessment dated 6/15/22, showed the patient was discharged home with IV infusion. Documentation showed the SN cleansed right upper arm insertion site PICC with alcohol swabs X 3 then with chlorhexidine, applied Biopatch, and cover with SorbaView dressing weekly maintaining sterile technique. Review of the SN notes failed to show documented evidence the injection caps were changed on Week 2 (5/29/2 to 6/4/22) and Week 5 (6/19/22 to 6/25/22). On 3/29/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 10's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 5/2/19. The patient was certified for home health services during the certification period from 12/12/22 to 2/9/23 and 2/10/23 to 4/10/23. The POC for the certification periods from 12/12/22 to 2/9/23, cited for SN visit 2W9, 2 PRN for wound and safety complications. The POC also showed SN to assess body system. Review of the Resumption of Care OASIS dated 1/30/23, showed the SN performed integumentary interventions and goals. The SN interventions included an abdominal incision x3 closed with derma glue leave open to air. The goals include incisions to the abdomen will heal within the certification period. Review of the SN notes dated 2/2/23, showed the SN performed skin assessment. The skin assessment included a comment for abdominal incisions no drainage and no signs of symptoms of infection. The assessment also includes pain in the abdomen with an intensity of 5 described as dull pain. Review of the Recertification OASIS dated 2/6/23, showed the RN had performed the comprehensive assessment. However, the comprehensive assessment failed to show documented evidenced of the abdominal wound as identified on 2/2/23. On 3/29/23 at 0935 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was asked if the abdominal wound was assessed. The RN QA replied, we need to document but there was no documentation. The RN QA was informed and acknowledged the findings. 1. Review of Patient 7's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 12/3/21. The patient was certified for home health services during the certification period from 1/27/23 to 3/27/23. The POC, for the certification period from 1/27/23 to 3/27/23, showed for the SN to cover the right upper chest with gauze, maintaining pressure for five minutes, and secure the dressing with tape while maintaining sterile technique after removing the needle from the port. On 3/23/23 at 1050 hours, a joint home visit was conducted with RN 1 to Patient 7’s home. RN 1 was observed accessing the patient’s right upper chest port-a-cath by inserting a non-coring needle and then flushing the medications into the port as per the order. After removing the needle, RN 1 placed a gauze over the port-a-cath site and secured it with tape. RN 1 then took the gloves off, sanitized her hands, donned a new pair of gloves, and proceeded to auscultate the patient’s abdomen. RN 1 did not maintain pressure on the site for five minutes as cited in the POC. On 3/23/23 at 1116 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared the accurate clinical notes for five of 13 sampled patients (Patients 2, 5, 7,10, and 11), creating the increased risk of substandard healthcare outcomes to these patients. #. Review of Patient 5's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 4/11/22. The patient was certified for home health services during the certification period from 2/5/23 to 4/5/23. Review of some of the SN notes showed inconsistencies related to the wound care provided for the patient. For example: The SN note dated 2/20/23, showed wound care to “right plantar foot/R great toe no TX needed at this time right plantar foot cleanse with NS, applied ColActive plus AG, cover with dry dressing, wrap with Kerlix, wrap with ace wrap and secure with tape.” However, the note showed a part of the documentation that no treatment was needed at this time to the right plantar foot; and another part of the documentation showed treatment was performed to the right plantar foot. On 3/29/23 at 841 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 1/31/23. The patient was certified for home health services during the period from 1/31/23 to 3/31/23. Review of the SN visit notes showed the SN visited the patient’s home on 3/20/22; however, there was no documented evidence showing the SN assessed the patient’s social/psychosocial support during the visit. On 3/29/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the finding. XX. Review of Patient 11's closed clinical record was initiated on 3/22/23. The clinical record showed the SOC was 7/2/21. The patient was certified for home health services during the period from 8/31/21 to 10/29/21. Review of the SN visit notes showed the SN visited the patient’s home on 9/17/21; however, there was no documented evidence showing the SN assessed the patient’s genitourinary system during the visit. On 3/29/23 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the finding. 1a. Review of Patient 7's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 12/3/21. The patient was certified for home health services during the certification periods from 11/28/22 to 1/6/23 and1/27/23 to 3/27/23. Review of the POC for the certification periods from 11/28/22 to1/26/23 and 1/27/23 to 3/17/23 cited RN/LVN visit as one visit every two months and 2 PRN for change in schedule. Review of the Recertification OASIS dated 11/27/23, showed SN visit frequency as every 2 months and 2 PRN for symptom management and change in schedule. However, review of the Physician Orders dated 11/27/22 showed an order for the SN visit frequency as one time every eight weeks, 3 PRN for change in schedule. On 3/29/23 at 0958 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was asked as to the frequency of PRN visits, the RN QA replied, needed to follow the POC which was 2 PRN visits, not the MD order dated 11/27/22. She was informed and acknowledged the findings. b. Review of the POC for the certification period from 1/27/23 to 3/17/23 cited RN/LVN visit as one visit every two months and 2 PRN for change in schedule. Review of the Recertification OASIS dated 1/26/23, showed SN visit frequency as every 2 months and 2 PRN for change in schedule. However, review of the Physician Orders dated 1/26/23 showed an order for the SN visit frequency as one time every eight weeks, 3 PRN. On 3/29/23 at 1012 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was asked as to the frequency of PRN visits, the RN QA replied, it was an incorrect transcription, needed to follow the POC which was 2 PRN visits. She was informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 3/23/23. The clinical record showed the SOC was 5/2/19. The patient was certified for home health services during the certification period from 12/12/22 to 2/9/23. Review of the Physician Order dated 12/8/22, showed the SN visit frequency cited for 2W9, 3PRN for wound issue. In addition, review of the Recertification OASIS dated 12/8/22, showed the SN visit frequency cited for 2W9, 3PRN for wound issue. However, review of the POC for the certification period from 12/12/22 to 2/9/23 cited for 2W9 and 2 PRN for wound and or safety complications instead of 3 PRN visits. On 3/29/23 at 0935 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was asked as to the frequency of PRN visits, the RN QA replied, needed to follow the 3 PRN, the 2 PRN on the POC was an inaccuracy of notes. She was informed and acknowledged the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge summaries were completed for two of the 13 sampled patients (Patient 12 and 13), creating the risk of substandard care provided to these patients as their clinical information were not complete. 2. Review of Patient 13's closed clinical record was initiated on 3/22/23. The clinical record showed the SOC was 5/25/22. The patient was certified for home health services during the certification period from 5/25/22 to 7/23/22. The patient was discharged on 6/29/22. The Discharge Summary dated 6/29/22, showed no documented evidence the discharge summary included the medications the patient was on at the time of discharge. On 3/29/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. The agency's P&P titled Discharge Criteria and Process dated 5/1/02, showed the discharge procedure includes upon discharge to self-care, the client will receive verbal/written instructions regarding medication use. Review of Patient 12's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 5/2/22. The patient was certified for home health services during the certification periods from 5/2/22 to 6/30/22 and was discharge on 6/17/22. The POC, for the certification period from 5/2/22 to 6/30/22, cited SN visits daily for four days, 1W3 (one time a week for three weeks) and 1 PRN for IV complication and midline removal. Review of the Physician Orders dated 6/17/22, showed an order for discharge. Review of the OASIS discharge dated 6/17/22, showed a section for the discharge summary. The discharge summary includes the section for the medication profile provided. However, the section for the medication profile provided was left blank. On 3/29/23 at 1115 hours an interview with concurrent closed clinical record review was conducted with the RN QA and the DPCS. They were asked if the medication profile needed to be filled out. The DPCS stated, no, unless it's not in the patient home folder. They were informed and acknowledged the findings.

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 interview and record review, the hospice failed to timely authenticate the entries made into the clinical record for seven of 13 patients (Patients 1, 2, 3, 7, 9,11, and 12), creating the risk of not having the complete and accurate information. XX. Review of Patient 2's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 1/31/23. The patient was certified for home health services during the period from 1/31/23 to 3/31/23. Review of the SN visit notes showed the SN conducted a home visit on 2/2/23. However, the form was electronically signed on 3/20/23. On 3/23/23 at 0932 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the findings. XX. Review of Patient 3's clinical record was initiated on 3/21/23. The clinical record showed the SOC was 12/15/22. The patient was certified for home health services during the period from 2/13/23 to 4/13/23. Review of the SN visit notes showed the SN conducted a home visit on 2/17/23. However, the form was electronically signed on 3/20/23. On 3/23/23 at 0946 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the findings. XX. Review of Patient 11's closed clinical record was initiated on 3/22/23. The clinical record showed the SOC was 7/2/21. The patient was certified for home health services during the period from 8/31/21 to 10/29/21. Review of the POC, showed the POC was created on 8/31/21; however, the form was electronically signed on 11/23/21. Review of the OASIS Discharge form showed the SN visited the patient’s home on 9/25/21; however, the form was electronically signed on 11/23/21. On 3/23/23 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator and RN 2. Both were informed and acknowledged the findings. 1.The agency's P&P titled Documentation Tracking Authentication of Clinical Record revised 3/1/12, showed after the visit, the discipline completes the visit documentation. If it is the start of care or OASIS, the documentation is to be within 2 days and complete within 5 days. Review of Patient 12's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 5/2/22. The patient was certified for home health services during the certification periods from 5/2/22 to 6/30/22 and was discharge on 6/17/22. Review of the OASIS SOC dated 5/2/22, showed the RN visited the patient to perform the initial comprehensive assessment. However, review of the POC for the certification period from 5/2/22 to 6/30/22, showed the RN electronically signed the POC on 5/24/22. On 3/29/23 at 0839 hours, an interview with the RN QA, the RN QA was asked as to why the POC was created/signed on 5/24/22. The RN QA replied, the RN submitted the POC late and that was the date that will show on the POC. She further stated, the OASIS was completed late dated 5/24/22. The RN QA was also asked as to the timeline of the submission of the POC. She replied, the POC should be submitted within five days from the visit date. She was informed and acknowledged the findings. 2. Review of Patient 7's clinical record was initiated on 3/23/23. The clinical record showed the SOC was 12/3/21. The patient was certified for home health services during the certification periods from 11/28/22 to 1/6/23 and1/27/23 to 3/27/23. * Review of the Recertification OASIS dated 11/27/22, showed the RN visited the patient to perform the comprehensive assessment. However, review of the POC for the certification period from 11/28/22 to 1/26/23, showed the RN electronically signed the POC on 1/20/23. On 3/19/23 at 0958 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was informed and acknowledged the findings. * Review of the Recertification OASIS dated 1/26/23, showed the RN visited the patient to perform the comprehensive assessment. However, review of the POC for the certification periods from 1/27/23 to 3/17/23, showed the RN electronically signed the POC on 2/13/23 which was 17 days after the comprehensive visit assessment. On 3/19/23 at 1012 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was informed and acknowledged the findings. 3. Review of Patient 9's closed clinical record was initiated on 3/23/23. The clinical record showed the SOC was 2/22/23. The patient was certified for home health services during the certification period from 2/22/23 to 4/22/23. Review of the Physician Orders dated 2/22, 3/10 and 3/22/23, showed the RN had electronically signed the order. Review of the Physician Orders included a section for a verbal or non-verbal orders. The orders showed the following: - verbal order received by - date order received - verbal order read back and verified - verbal order received from - time order received and - effective date However, section where the RN needed to fill out was left blank. On 3/29/23 at 1035 hours, an interview with concurrent clinical record review was conducted with the RN QA. The RN QA was asked if the orders were a verbal or non-verbal order. The RN QA replied, it should have been filled out. She was informed and acknowledged the findings. The agency's P&P titled Documentation Tracking Authentication of Clinical Record revised 3/1/12, showed after the visit, the discipline completes the visit documentation. If it is the start of care or OASIS, the documentation is to be within 2 days and complete within 5 days. If it is a routine visit, the documentation is to be done within 30 days or sooner pending on payer’s status. 1. Review of Patient 1's clinical record was initiated on 3/20/23. The clinical record showed the SOC was 12/24/22. The patient was certified for home health services during the certification periods from 12/24/22 to 2/21/23 and 2/22/23 to 4/22/23. The follow-up recertification assessment dated 2/19/23, showed the form was electronically signed on 3/20/23 by the DNP, which was more than five days. The Wound Care Flow Sheets dated 12/28, 1/4, 1/11, 1/25, 1/31, and 2/8/23, showed the form was electronically signed by the DNP on 3/20/23, which was more than 30 days. The Wound Care Flow Sheets dated 1/17/23, showed the form was electronically signed by the DNP on 3/21/23, which was more than 30 days. The SN notes dated 1/17, 1/25, and 1/31/23, showed the form was electronically signed by the DNP on 3/20/23, which was more than 30 days. On 3/29/23 at 0900 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding