Every finding on record at Physicians Choice Home Health, Inc

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: *

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the physician reviewed/revised and signed the individualized plan of care for 2 of 5 patients (patient 2 and 5). This deficient practice had the potential of care ordered by the physician not being provided and supervised by the physician. b. On 9/23/22, a review of Patient 5’s electronic clinical record the document titled , “Outcome and Assessment Information Set (OASIS) and Plan of Care(POC)”, with the certification period from 8/26/22 to 10/24/22, indicated a (SOC) date of 8/26//22, with diagnosis that included Encounter for change or removal of surgical wound dressing , malignant otitis externa, left ear and (, low back pain, The physician instructed the Skilled Nurse (SN) to visit patient to assess neurological status , cardiovascular status and to treat/dress posterior left ear. one time a week for 1 week. On 9/26/22, at 1 p.m., during a concurrent record review and interview with the director of patient care services (DPCS), the DPCS stated, Patient 5’s authorization request physician’s order dated 8/26/22, was not sign by the physician. Continued review of patient 5’s clinical record indicated Patient 5’s plan of care was not signed by the physician. During a joint interview with the DPCS and administrator on 9/26/22, at 2Pm, they stated the forms should have been signed by the physician within 30 days. a. A review of Patient 2’s plan of care (POC) for certification period 8/18/22-10/16/22, indicated a start of care date (SOC) of 8/18/22, with a primary diagnosis of malignant neoplasm of left bronchus (left lung cancer). According to the POC Patient 2 would receive skilled nursing visits two time a week from 8/18/22-8/20/22 for assessment of respiratory status, and to educate family on how to preform plural effusion drainage (removal of fluid around the lungs through a tube that was surgically inserted into the chest). However, the POC was completed and signed by the Registered Nurse (RN) on 8/18/22, but has no physician signature on the POC. During an interview on 9/26/22 at 2:04 pm, director of patient care services (DPCS), DPCS stated, Patient 2’s POC was not signed by doctor. DPCS stated that the doctors have 30 days to review and sign the POC to make sure it includes all orders needed for the patients. A review of the HHA’s policy titled “Physician Participation in Plan of Care”, dated 5/2022, indicated that the attending physician will sign the plan of care/treatment within 30 days of the start of care.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: *

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA) failed to conduct nutritional status (as an individual's health condition as it is influenced by the intake and utilization of nutrients) assessment was assessed for one of 5 sampled patients (Patient 1). Patient 1 was taking nutritional supplement drink and was not taking solid foods and nursing staff did not notify the physician. This failure had the potential for Patient 1 not receiving to adequate nutrition that could cause weight loss and not to meet patient care goals. A review pf Patient 1’s Patient Profile indicated a start of care date (SOC) of 6/26/22 with diagnosis of stage 3 pressure ulcer of sacrum (open wound on buttocks, caused by prolonged pressure on the skin), Type 2 diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), and dementia (brain condition that can cause memory loss and impaired judgment), and dysphagia (difficulty swallowing foods or liquids). During home visit conducted on 9/23/22 at 10 am, with licensed vocational nurse 1 (LVN 1) at the patient's home. Patient 1’s in-home caregiver (Caregiver 1) was present. When asked by LVN 1 if patient was on a diabetic diet, Caregiver 1 stated that Patient 1 was not eating any food and would only drinking Ensure Max Protein shake three times a day. The Ensure bottle was observed, each bottle was 11 ounces (oz-unit of measurement), 150 calories, one gram of sugar, and six grams of carbohydrate. Caregiver 1 stated that they do not weigh the patient. A review of Patient 1's medication profile for certification period 8/25/22-10/23/22 indicated that Patient 1 was to take nutritional supplement Boost Plus (a drink to increase calorie intake). The order was to take one bottle as needed if patient has low appetite. A review of Patient 1’s plan of care (POC) for certification period 8/25/22-10/23/22, indicated that Patient 1 was to be on a diabetic low carbohydrate diet effective start date of 6/26/22 and to have Ensure max protein nutrition shake 8oz, 2 bottles a day starting 8/30/22. During an interview on 9/23/22, at 1:30pm, Patient 1’s family representative (REP 1) stated that Patient 1 does not want to eat any food and has difficulty swallowing solid foods. Patient has only been drinking the high protein Ensures for the past three to six months. Rep 1 stated that Patient 1 has been losing weight but does not know how much weight loss. During an interview on 9/26/22, at 1:02pm, LVN 2 stated that she was told that Patient 1 only supplements with Ensure two times a day, before breakfast and after dinner. LVN 2 stated, Patient 1 on diabetic diet and the caregiver provided Patient 1 protein and vegetables to eat. LVN 2 stated, Patient 1 was still eating whole foods, but she had not observed Patient 1 eat. LVN 1 stated that she did not know if Patient 1 has difficulty swallowing, she has only been seeing her for about 2 weeks and she has not noticed any weight loss. During an interview on 9/26/22, at 1:21 pm, Caregiver 2 stated, Patient 1 stopped eating solid foods in December of 2021 and Patient 1 taking Ensure Max Protein 2.5 bottles a day. Caregiver 2 stated, Patient 1 was not eating any other foods except for the Ensures. Caregiver 2 stated, Patient 1 has lost some weight, but did not know how much, the last weight was 140 pounds (lbs.) taken in July when the patient was in the hospital and her arms and legs look smaller. A review of the Patient 1’s medical record only showed a documented weight on the Oasis Start of Care conducted on 6/26/22, for certification period of 6/26/22-8/24/22. Patient 1’s weight was recorded as 150 lbs. and the documentation indicated that the weight was obtained through weight reported or from medical records. Patient 1 was not weighed by nurse at SOC. A review of Patient 1’s general acute care hospital (GACH) records dated 7/22/22 indicated a weight of 150lbs. During an interview on 9/26/22, at 12:13pm, the Director of Patient Care Services (DPCS) stated that she was not aware that Patient 1 was not eating meals and only drinking Ensures. DPCS stated that based on the orders the Ensures should be used as supplements to meals. DPCS stated that the nurse should be reviewing the POC and assessing the patients nutrition. Patient 1 only taking Ensure should have been concern to the nurse. DPCS stated that the nurse should have notified clinicians at the office and the doctor that the patient that only drinking Ensures. Patient 1’s weight could have been monitored and Albumin levels (blood test) could be taken to help assess nutrition status. A review of Patient 1’s medical chart did not indicate that the doctor was made aware of the patient’s current diet, nor were there any orders for weight monitoring, or blood test orders. A review of the HHA’s policy titled “Ongoing Assessment”, dated 5/2022, indicated that During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter. Patient appetite/diet, nutritional status is part of the reassessment. The policy also indicated that based on each reassessment, the plan of care, including problems, needs, goals, and outcomes will be reviewed and revised accordingly by the clinician. Based on the findings of the reassessment, change/verbal orders will be generated and forwarded to the physician as needed. A review of the HHA’s policy titled “Nutrition Assessment”, dated 5/2022, indicated that when the initial and comprehensive assessment indicates a alteration in nutritional status, the clinician will make a referral to a qualified health care professional for further nutritional assessment. The policy indicated that during the assessment, if the clinician has any concerns related to diet/appetite, weight, or dysphagia the clinician will contact the patient’s physician to obtain orders for nutritional consult.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure supervisory registered nurse (RN) visits were conducted for one of five sampled patients (Patient 1). This failure had the potential for Patient 1 not to receive adequate nursing care from the licensed vocational nurse (LVN). A review of Patient 1’s Patient Profile indicated a start of care date (SOC) of 6/26/22 with diagnosis of stage 3 pressure ulcer of sacrum (open wound on buttocks, caused by prolonged pressure on the skin), Type 2 diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), and dementia (brain condition that can cause memory loss and impaired judgment), and dysphagia (difficulty swallowing foods or liquids). A review of Patient 1’s Plan of Care (POC), for certification period 8/25/22-10/23/22, indicated that Patient 1 would receive skilled nursing visits three times a week for wound care and diabetes monitoring. Patient 1’s medical record was reviewed with the Director of Patient Care Services (DPCS), no documentation for RN supervisory visits for the LVN could be found. During an interview and record review on 9/26/22, at 12:30pm, the DPCS stated, there was no RN supervisory visits for the LVN's patient visit, documented on Patient 1's medical records. The DPCS stated, supervisor visits should be conducted every 30 days. The documentation would be found under “Nursing Notes” section the medical chart, but there was none. The DPCS stated, the RN would fill out a checklist form to confirm that the LVN has been provided proper care to the patient. DPCS stated that no documentation was found in Patient 1’s medical chart, and it was not done. The HHA was unable to requested policy for supervisory visits.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to maintain an accurate clinical record for one of five sampled patients (Patient 1). Patient 1’s Outcome and Assessment Information Set (OASIS) is the patient-specific, standardized assessment to monitor the quality of home health care to ensure that the needs of patients are properly met) recertification assessment on pressure ulcer documentation was inaccurate. This deficient practice had the potential to cause Patient 1 to received inappropriate wound treatments based on the incorrect documentation. A review of Patient 1’s Patient Profile indicated a start of care date (SOC) of 6/26/22 with diagnosis of stage 3 pressure ulcer (full thickness tissue loss, subcutaneous (under the skin) fat may be visible, but bone, tendon, or muscle is not exposed, slough may be present but does not obscure the depth of tissue loss) of sacrum. A review of Patient 1’s Oasis Recertification assessment conducted on 8/24/22 for certification period 8/25/22-10/23/22, indicated a primary diagnosis of pressure ulcer of right buttock, unstageable (wound known, due to coverage of wound bed by slough and/ or eschar [dead tissue, usually dry, dark scab]), dated 7/28/22. The nurse described the pressure ulcer as being stage 2 measuring 2.1 centimeters (cm-unit of measurement) long, 2.4 cm wide, and 0.5 cm deep, with sloughing (yellow/white material in the wound bed, usually a wet consistency. It consists of dead cells that accumulated in the wound) in the wound bed. According to the Oasis reassessment a stage 2 pressure ulcer is defined as a partial thickness loss of dermis (the thick layer of skin which contains blood capillaries, nerve endings, sweat glands and hair follicles) presenting as a shallow open ulcer with a red or pink wound bed, without slough. A review of Patient 1’s electronic medical record indicated that the last picture of Patients 1’ s buttocks wound was taken before the recertification (8/24/22) was on 8/12/22, and showed slough covering the wound bed, but depth of wound is obscured, which is indicative of an unstageable pressure ulcer based on the definition. There was no photo of Patient 1’s wounds taken during the assessment. During an interview on 9/29/22, at 11:44 a.m., the Administrator (ADM) and Director of Patient Care Services (DPCS) both stated, the documentation of the nurse on the assessment was incorrect, the pressure ulcer on the buttocks was not a stage 2. ADM and DPCS stated, photo of the wound should have been taken during the recertification assessment as part of the documentation for wounds, to help keep track of the healing progress. The ADM stated that the previous DPCS was the one responsible for reviewing nursing documentation, but it was not being done. Policy and Procedure for pressure ulcers and documentation was requested, the ADM stated that she could not find any policies.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 3220 Sepulveda Blvd. Suite 100 Torrance, CA 90505, and a complaint investigation for complaint number 62907 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 19096, Health Facilities Evaluator Nurse Unduplicated Admissions - 2742 Active Patients - 89 Sample Size - 10 Home Visits- 5 Three (3) Conditions of Participation not met: CFR 484.102- Emergency Preparedness CFR 484.60- Care planning, Coordination of Services, and Quality of Care CFR 484.75-Skilled Professional Services

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on observations, interviews, and record reviews, the home health agency (HHA) failed to meet the Condition of Participations for the Establishment of the Emergency Program by failing to: 1. Ensure 120 staffs had training and annual update regarding the emergency preparedness program (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) as indicated in their policy and procedure. (Refer to E0004) 2. Ensure the emergency preparedness plan/drill for field staffs were completed in an annual basis. (Refer to E0036) The cumulative effect of this deficient practice resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Establishment of the Emergency Program to ensure patients safety is maintained in cases a disaster or emergency crises does occur. ..

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure 120 staffs had training and annual update regarding the emergency preparedness program (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) as indicated in their policy and procedure. This deficient practice had the potential that staffs will not be able to provide the skills and knowledge on how to respond effectively during an emergency situations. During a review of the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) program or Emergency Operations Plan of the HHA on 8/9/2022 at 1:31 p.m., the agency was unable to provide documented evidence EP program or Emergency Preparedness training/disaster training was conducted to all the staffs employed by the agency. During an interview with the Director of Patient Care Services (DPCS) on 8/11/2022 at 12:29 p.m., the DPCS stated the staffs has their own supplies in their cars to use in an emergency situation. DPCS also stated orientation for emergency preparedness would be given at the time of hire. During a concurrent record review of the home health agency's in-service topic/schedule records showed that EP was scheduled in January, however, it did not indicate the date and time it was conducted. DPCS was not able to provide documented evidence to indicate all staffs had attended the in-service training on site, via telephone or video in-service. A review of the HHA's policy titled "Emergency Operations Plan", dated, 5/1/2017, indicated staff shall attend orientation upon hire and an annual update of their specific roles and responsibilities and the skills they require to perform their duties during an emergency.

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), §485.625(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, 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 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 in an annual basis. This failure had the potential to result in the staff lacking knowledge to respond effectively when an emergency/disaster situation occur. On 8/11/22 at 12:29 p.m., during an interview with the Director of Patient care services (DPCS), the DPCS stated that the office building and the fire marshal conducts emergency drills for office staff. DPCS stated that field staff carries basic supplies in their car for emergency services. DPCS further stated that the orientation for emergency operations are given to employees upon hire. A review of one field staff employee files did not indicate any documented evidence that the emergency operations orientation and in-services were done. A review of the home health agency's policy titled, "Emergency Operations Plan", revised 5/1/2017 indicated, the HHA's orientation and education program for those who participate in implementing the plan. Staff shall attend orientation upon hire and an annual update of their specific roles and responsibilities and the skills they require to perform their duties during an emergency. In-service education shall be given on the back up communication system and obtaining supplies /equipment in the event of an emergency. The HHA's Emergency Operations Plan shall be updated and documented at least annually and as needed. The safety director is responsible for the In-servicing staff at the organization-wide Emergency Operations Plan. The safety director shall be responsible for reviewing, documenting and updating the HHA's emergency preparedness training and testing program annually and as needed.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 3220 Sepulveda Blvd. Suite 100 Torrance, CA 90505, and a complaint investigation for complaint number 62907 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 19096, Health Facilities Evaluator Nurse Unduplicated Admissions - 2742 Active Patients - 89 Sample Size - 10 Home Visits- 5 Three (3) Conditions of Participation not met: CFR 484.102- Emergency Preparedness CFR 484.60- Care planning, Coordination of Services, and Quality of Care CFR 484.75-Skilled Professional Services

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on interview, and record review, the HHA failed to ensure the patient has the right to lodge complaint and be investigated promptly regarding the lack of treatment or care furnished, and failed to implement their policy and procedure on Concerns/Grievances of the patient's complaint for one of 10 patients (Patient 9). This deficient practice had resulted in the patient's complaint not being investigated. Findings: A complaint investigation was initiated on 4/26/22, at 12: 33 pm., regarding the patient (Patient 9) not being seen by the HHA's skilled nurse after conducting the initial assessment on 4/5/22, and Patient 9's request for a digital weighing scale. During telephone interview with Patient 9 on 5/3/22, at 2:23 pm, and on 8/10/22, at 3 pm, stated she only saw the SN one time which was on 4/5/22. Patient 9 stated she requested a digital weighing scale due to her vision declining. Patient 9 called the HHA numerous times due to no SN visits but was told by the agency's staff she was refusing the visit. Patient 9 stated she was never contacted by the HHA since that first visit. Patient 9 stated, she was homebound and had never refused the visits. Patient 9 stated she went to her physician to request another home health agency to provide the HHA services. During a telephone interview with Patient 9's caregiver (PCG) stated, Patient 9 never refused a visit and had given her number to the agency staff to call PCG instead of Patient 9 due to being ill and unable to answer the phone. The PCG stated no one from the agency visited Patient 9 since the first visit . During a review of Patient 9’s, “Outcome and Assessment Information Set (OASIS) and Plan of Care (POC)”, for certification period from 4/5/2022 to 6/3//2022, indicated a start of care (SOC) date of 4/5/2022. The diagnoses included Malignant neoplasm of the stomach, unspecified, weight loss, unsteady gait and generalized weakness. The physician ordered SN visit one time a week for three weeks. The SN was to assess/instruct patient and patient caregiver (PCG) diet/hydration to promote proper management of disease process, assess gastrointestinal status, monitor and record fluid intake/output, and check weights every visit. Review of Patient 9’s clinical record indicated a Nurse Patient Missed Visit dated 4/2/22, indicated Missed visit Initial evaluation delayed on 4/2/22, by RN 3. Patient 9’s clinical record also revealed a Nurse Patient Missed Visit dated 4/3/22, it indicated Missed visit Initial evaluation delayed on 4/3/22 secondary to Patient 9 refusing the visit and asked for the HHA to provide scale for patient to check her weight, RN 3 called DPCS to find out if SN must have scale, and was told "No" by the DPCS, and will "follow up in office tomorrow". There was no documented evidence the DPCS followed up with the physician of Patient 9's need for a digital scale or for the skilled nurses to have a scale to weigh Patient 9 every visit as indicated in the POC. A review of the HHA's Patient Complaint Log dated 4/23/22, identified Patient 9's name and under Nature of complaint, documents, indicated "Nurses did not come with scale and also dated 4/26/22, "DHS complaint visit . There was no other documented evidence the complaint was investigated or resolved. During an interview with the Director of Patient Care services on 4/26/22, and 8/12/22, states when a complaint comes in it is either assigned to an RN supervisor who investigates the complaint and that it could take 3 to 5 days to be investigated. The DPCS stated when she investigated the complaint the patient had already been discharged. On 8/10/22, DPCS could not provide documented evidence the complaint had been investigated and resolved nor could provide the time frame it took from the time the complaint was received to the time it was investigated. Review of the HHA's policy and procedures titled, " Patient Concerns/Grievances dated 9/1/2017 stipulated, "The information provided shall include the phone number, contact person, and the manner in which the concern/grievance shall be processed, including the time frame for processing." Continued review of the procedure of Patient concerns/Grievances dated 9/1/2017 stipulated, " The concern/grievance investigation shall commence within 48 hours of receipt of the written complaint. This time frame applies to any concern/grievance received after regular business hours, on weekends or holidays. The Patient Care Service Director will notify the patient/family within five (5) days of receipt of the concerns/grievances by telephone and/or e-mail, fax or letter to confirm receipt of the concerns/grievance, and to inform the individual (s) that the concern/grievance is under investigation. A record of the concern/grievance, investigation, follow-up action and response to the patient will be documented , using the Patient Complaint Form and will be retained by Administration in the Patients Complaint file. This form is to be initiated by the person receiving the concern/grievance."

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview, and record review, the HHA failed to ensure one of 10 sample patients (Patient 9) received all services ordered in the plan of care (POC). This deficient practice resulted in the patient not receiving the services and treatments and not meeting the patient's health needs identified in the POC. Findings: A complaint investigation was initiated on 4/26/22, at 12: 33 pm., regarding the patient (Patient 9) not being seen by the HHA's skilled nurse except for her initial assessment on 4/5/22, and her request for a digital scale. During telephone interview with Patient 9 on 5/3/22, at 2:23 pm, and on 8/10/22, at 3 pm., stated she only saw the SN one time which was on 4/5/22. Patient 9 stated she requested a digital scale due to her vision declining and called the HHA numerous times due to no skilled nurse visits only to be told she was refusing visit. Patient 9 stated she was never contacted by the HHA staff after that first visit. Patient 9 stated she was homebound and never refused the visits. Patient 9 stated she went to her physician to request another agency who could provide the services. During a telephone interview with Patient 9's caregiver (PCG) stated Patient 9 had never refused a visit, and the PCG gave the staff her number to call her instead of Patient 9 due to being ill and unable to answered the phone. The PCG stated no one has visited Patient 9 since the first visit nor had agency called her to make arrangements. The PCG stated Patient 9 never refused a skilled nurse visit, and the skilled nurses just never came back. During a review of Patient 9’s Outcome and Assessment Information Set (OASIS) and Plan of Care (POC) for certification period from 4/5/2022 to 6/3//2022, indicated a start of care (SOC) date on 4/5/2022, with diagnoses that included malignant neoplasm of the stomach, unspecified, weight loss, unsteady gait and generalized weakness. The physician ordered Skilled nursing visit one time a week for three weeks to assess/instruct patient and patient caregiver (PCG) diet/hydration to promote proper management of disease process, Assess Gastrointestinal status, monitor and record fluid intake/output, and check weights every visit. During a telephone interview with the RN 1 on 4/26/22, at 3:16 p.m., stated she did the initial assessment and Patient 1 was somewhat angry due to two missed visit prior to me coming. RN 1 stated, “ I may have dropped the ball. RN stated she was supposed to call the HHA after initial visit and request for follow-up visit with License Vocational Nurse (LVN) however, since she just restarted with this HHA she did not know she was supposed to sign off.” During an interview with RN 1 on 8/12/22, at 11:30 am., stated Patient 9 was her first patient since returning back to the HHA after leaving them in 2017, and that she was never orientated by the agency regarding signing off initial evaluations. RN 1 stated she visited Patient 9 one time which was during the initial evaluation and completed the SBAR (situation, background, assessment and recommendation) regarding Patient 9's need for a digital scale and her need for physical therapy due to her unsteady gait and generalized weakness. During a concurrent interview with the Administrator (ADM) and Director of Patient Care Services (DPCS) on 8/12/22, at 12:30 p.m., during the on-site complaint investigation stated, the nurse who assessed Patient 1 did not call the office and put the patient on the schedule so the nurses did not have to schedule and that was how Patient 1's visits were missed. The ADM stated the Registered Nurses (RN ) are the case managers and we tried to schedule a visit as soon as we found out. "It was a communication failure with our staff." Review of the Incident Report dated 4/25/22, completed by the DPCS, it indicated," Delay in starting SOC. Planned visits 1 time a week x 3 weeks with no follow up by SN who stated she would be following patient."

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, and current medication profiles for 2 of 5 patients (Patients 1, and 2). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. Findings: 1. A review of Patient 1's Patient Profile Information indicated, a start of care (SOC) date of 7/15/22, with a certification period of 7/15/22 to 9/12/22. Patient 1's diagnosis included type 2 diabetes (is a chronic condition where the body does not produce insulin which regulates the blood sugar) with skin ulcer (an open sore in the skin). A home visit was conducted on 8/10/22 at 10:15 a.m., with Licensed Vocational Nurse 1(LVN 1). Patient 1 was observed sitting in the dining area, alert and oriented to name, place, and time, not in any respiratory distress. During a review of Patient 1's medications currently taking reconciling with the medication profile on 8/10/22, at 10:30 a.m., indicated the following medications were not updated in the medication profile: Metoprolol 100 Hydrochlorothiazide (HCTZ) 12.5 mg 1 tablet daily for high blood pressure. Patient 1 stated it was changed to Metoprolol 100 mg 1 tablet dailyHCTZ 25 mg 1 tablet daily for high blood pressure. Patient 1 stated not taking this medication anymoreCalcium Carbonate 1200 mg with Vitamin D 1000 mg 1 tablet daily as supplement. Patient 1 stated she was not taking it anymore. Patient 1 stated it is changed to Vitamin D 1000 mg daily. During a wound care observation on 8/10/22, at 11:45 a.m., Patient 1 was observed closing her eyes while LVN 1 performed the wound care. Patient 1 stated that she takes a combination of over-the-counter Advil and Tylenol together when pain becomes unbearable. Advil and Tylenol were not listed in the current medication profile. During a concurrent interview on 8/10/22 at 10:30 a.m., LVN 1 stated she reviewed Patient 1’s medications at least once a week. 2. A review of Patient 2's Patient Profile Information for certification period of 6/17/22 to 8/15/22, indicated a SOC date of 6/17/22. Patient 2's diagnosis included chronic respiratory failure (is a long-term condition that happens when your lungs cannot get enough oxygen into your blood) with hypoxia (is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin). A home visit was conducted on 8/10/22, at 11:45 a.m., was observed with Licensed Vocational Nurse 3(LVN 3). Patient 2 was sitting in the living room, alert and oriented to name, place, and time. During a review of Patient 2's medications currently taking reconciling with the medication profile on 8/10/22, at 12:30 p.m., indicated the following medications not updated in the medication profile: Aspirin 81 mg 1 tablet daily as blood thinner. Patient 2 stated he was not taking Aspirin for 5 weeks.Carvedilol 6.25 mg 1 tablet twice daily for blood pressure. Patient 2’s bottle indicated Carvedilol 6.25 mg 1 tablet every Mondays, Wednesdays and Fridays.Potassium Chloride ER 10 MEQ(milliequivalent-a unit of measure) 1 capsule daily. Patient 2’s bottle indicated to take four times a week. Patient 2 did not indicate which days he takes this medication.Colace 100 mg 1 capsule daily as needed for constipation. Patient 2 stated that “I rarely take that” but does not have a bottle available in the home. Finasteride 5 mg 1 tablet daily for enlarged prostate but was not listed in the medication profile. During an interview on 8/10/22 at 12:40 p.m., with LVN 3 stated she reviewed Patient 2’s medication once a week if there was anything new. A review of the HHA’s policy titled “Medication Management Program” revised on 5/1/2017 indicated to improve the performance of medication management processes, thereby continuously improving patient health outcomes and reducing the occurrence of medication-related errors and medication-related adverse patient outcomes, including adverse reactions. For the purpose of this program the definition of medication shall include: prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals (substances not controlled by the FDA), over the counter medications, vaccines, radioactive medications, respiratory treatments, parenteral nutrition, blood derivatives, intravenous solutions and any product designated by the FDA as a drug. A review of the HHA’s policy titled “Patient medication Information/Reconciliation” revised 4/1/2017 indicated The medication profile is completed in its entirety, including dosage, frequency, and administration routes, according to HHA policy. Patient medication profile/reconciliation shall be conducted by a registered nurse/qualified healthcare staff and is a multidisciplinary process involving patient/family. Patient’s medications are reviewed and assessed during each skilled visit. Any changes to the medications or changes in the patient’s response to the medications are conveyed to the ordering physician.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the Home Health Agency (HHA) failed to meet the Conditions of Participation for Care planning, Coordination, and Quality of care as follows: The HHA failed to follow plan of care (POC) of one of 10 sampled patients (Patient 9), Patient 9 had one skilled nurse (SN) visit for the certification period of 4/5/2022 to 6/3/2022, when thew POC was to visit the patient once a week. The HHA did not notify the physician of the missed SN visit. The failure could result in the delay of patient's progress to care goal. (G572) The HHA failed to provide digital scale (a measuring device that reads and displays the weight of an object), to the patient, as orderd by the physician. This failure had a potential not to monitor patient's weight. (580). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest health care is provided to patients assessed to receive home health services. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview, and record review, the HHA failed to follow the patient's plan of care (POC) for 1 or 10 patients (Patient 9). Patient 9 had one skilled nurse (SN) visit, when the certification period 4/5/22 to 6/3/22 indicated for SN to visit once a week. The HHA did not notify the physician of the missed visit. This deficient practice has the potential to delay the progress to patient's care goals. Findings: During telephone interview with Patient 9 on 8/10/22, at 3 p..m, the patient stated, she only saw the SN one time which was on 4/5/22. Patient 1 stated she requested a digital scale due to her vision declining and called the HHA numerous times due to no skilled nurse visits only to be told she was refusing visit. Patient 9 stated, she has never been contacted by the HHA since their first visit, she is homebound and has never refused visits. Patient 9 stated, she never heard back from the HHA and she went to her physician to request another agency who could care for her. During the telephone interview the caregiver of Patient 9 stated, Patient 9 has never refused a visit and the caregiver gave the agency her number to call, due to Patient 9 being ill and could not answer the phone. The PCG stated no one from the agency had visited Patient 9 since the first visit on 4/5/22, nor have they called her to schedule a visit for the patient. The PCG stated Patient 1 did not refused a skilled nurse visit. A review of Patient 9’s medical record titled, “Outcome and Assessment Information Set(OASIS) and Plan of Care (POC)”, with the certification period from 4/5/2022 to 6/3//2022, indicated a start of care (SOC) date on 4/5/2022, with diagnosis that included malignant neoplasm (a cancerous tumor, an abnormal growth that can grow uncontrolled and spread to other parts of the body) of the stomach, unspecified, weight loss, unsteady gait and generalized weakness. The physician ordered skill nursing visit one time a week for three weeks to assess/instruct patient and patient caregiver (PCG) diet/hydration to promote proper management of disease process, Assess Gastrointestinal status, monitor and record fluid intake/output, and check weights ever visit. During a concurrent interview with the Administrator (ADM) and Director of Patient Care Services (DPCS) on 4/26/22, at 1: 30 p.m., in the kitchenette area of the HHA during the on-site complaint investigation stated the Nurse who assessed patient 1 did not call in the office and put the patient put on the schedule so the nurses did not have it on the schedule and that is how patient 1 visits were missed. The ADM. sated the Registered Nurses (RN) are the case managers and we tried to schedule a visit as soon as wee found out. It was a communication failure with our staff. During a telephone interview with the RN 4/26/22, at 3:16 p.m., she stated she did the initial assessment and Patient 1 was somewhat angry due to two missed visit prior to me coming. RN ? stated, “ I may have dropped the ball. RN stated she was supposed to call the HHA after initial visit and request for follow-up visit with License Vocational Nurse (LVN) however, since she just restarted with this HHA she did not know she was supposed to sign off.” During a telephone interview with Registered Nurse (RN) on 8/12/22 at 1:30 p.m., she stated she only saw the patient one time, she requested a digital scale and Physical Therapy due to unsteady gait and generalized weakness and that she was never orientated to the HHA’s policy and procedure, Patient 9 was her first case on 4/26/22 at 12:37 p.m. RN stated, she was never informed she had to sign off. Review of Patient 9’s medical record indicated a Nurse Patient Missed Visit dated 4/2/22, indicated missed visit Initial evaluation delayed on 4/2/22, by RN 3 secondary to (form blank ). Nurse Patient Missed Visit dated 4/3/22, indicated missed visit Initial evaluation delayed on 4/3/22, secondary to Patient 9 refused visit since the patient and the PCG requested for a digital scale, for the patient to check her weight, RN 3 called DPCS to see if SN must have scale and was told "No" from DPCS who she will follow up in office tomorrow. There was no documented evidence the DPCS follow-up with Patient 9's physician regarding the scale of the missed visits. Review of Patient 9’s medical record indicated a "Nurse Patient Missed Visit" dated 4/15/22, indicated missed visit by RN1 on 4/15/22 secondary to the patient did not appear to be home for appointment (i.e. no answer). The HHA form “Nursing Visit Record” dated 4/20/22 Time In : 1:00 PM- Time Out 1:45 pm. Signed by patient 1 on 4/26/22 at 10:07:31 AM and electronically signed by RN 1 on 4/26/22, at 10:05:47 AM. The HHA form "Nurse Patient Missed Visit" dated 4/23/22, indicated missed visit electronically signed by RN 2 on 4/23/22 secondary to Patient 9 refused SN visit, and transferred to another agency but does not know the name of the agency.” There was no documentation on Patient 9's medical record the physician was notified by the HHA regarding the missed visit and patients request for a digital scale.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview, and record review, the HHA failed to ensure patient care and services are furnished as ordered by the physician for 1 or 10 patients ( Patient 9). This deficient practice has the potential risk that could affect the patient's health status and well being. Findings: A complaint investigation was imitated on 4/26/22, at 12: 33 pm., regarding the patient not being seen by the HHA's skilled nurse except for her initial assessment on 4/5/22 and her request for a digital scale. During telephone interview with Patient 9 on 5/3/22 at 2:23 pm., and on 8/10/22, at 3 pm, she stated she only saw the SN one time which was on 4/5/22. Patient 1 stated she requested a digital scale due to her vision declining and called the HHA numerous times due to no skilled nurse visits only to be told she was refusing visit. Patient 1 stated she has never been contacted by the HHA since their first visit, she is homebound and has never refused visits. Patient 1 stated she never heard back from the HHA and she went to her physician to request another agency who could care for her. During a telephone interview with the caregiver of patient 1 she stated Patient 1 has never refused a visit and the caregiver gave staff her number to call due to Patient 1 being ill an unable to answered the phone. The PCG stated no one has visited Patient 1 since the first visit nor have they called her to make arrangements. The PCG stated Patient 1 has ever refused a skilled nurse visit and the skilled nurses just never came back . During a Recertification survey/complaint investigation on 8/9/22 through 8/12/22, review of Patient 9’s clinical record, the document titled, “Outcome and Assessment Information Set(OASIS) and Plan of Care (POC)”, with the certification period from 4/5/2022 to 6/3//2022, indicated a start of care (SOC) date on 4/5/2022, with diagnosis that included malignant neoplasm of the stomach, unspecified, weight loss, unsteady gait and generalized weakness. The physician ordered Skill nursing visit one time a week for three weeks to assess/instruct patient and patient caregiver (PCG) diet/hydration to promote proper management of disease process, assess gastrointestinal status, monitor and record fluid intake/output, and check weights every visit. During a concurrent interview with the Administrator (ADM) and Director of Patient Care Services (DPCS) on 4/26/22, at 1: 30 p.m., in the kitchenette area of the HHA, during the on-site complaint investigation stated the Nurse who assessed Patient 1 did not call in the office and put the patient put on the schedule so the nurses did not have it on the schedule and that was how Patient 1 visits were missed. The ADM sated the Registered Nurses (RN) are the case managers and we tried to schedule a visit as soon as wee found out. It was a communication failure with our staff. During a telephone interview with the RN 3 4/26/22, at 3:16 p.m., she stated she did the initial assessment and Patient 1 was somewhat angry due to two missed visit prior to me coming. RN stated, “ I may have dropped the ball. RN stated she was supposed to call the HHA after initial visit and request for follow-up visit with License Vocational Nurse (LVN) however, since she just restarted with this HHA she did not know she was supposed to sign off.” During a telephone interview with RN 3 on 8/12/22, she stated she only saw the patient one time, she requested a digital scale and Physical Therapy due to unsteady gait and generalized weakness and that she was never orientated to the HHA’s policy and procedure Patient 1 was her first case. On 4/26/22 at 12:37 p.m. in the kitchenette area she was never informed she had to sign off. Review of Patient 1’s clinical record indicated a Nurse Patient Missed Visit dated 4/3/22, indicated Missed visit Initial evaluation delayed on 4/3/22 secondary to Patient refused visit since with family and sked for HHA to provide scale for patient to check her weight, RN 3 called DPCS to see if SN must have scale and was told No from DPCS who she will follow up in office tomorrow. Review of Patient 1’s clinical record indicated a Nurse Patient Missed Visit dated 4/15/22, indicated Missed visit by RN 1 on 4/15/22 secondary to Patient did not appear to be home for appointment (i.e. no answer). Review of Patient 1’s clinical record indicated a Nurse Patient Missed Visit dated 4/2/22, indicated Missed visit Initial evaluation delayed on 4/2/22 secondary to (form blank ) electronically signed by RN3 Review of Patient 1’s clinical record indicated the HHA form “Nursing Visit Record” dated 4/20/22 Time In : 1:00 PM- Time Out 1:45 pm. Signed by patient 1 on 4/26/22 at 10:07:31 AM and electronically signed by RN 1 on 4/26/22, at 10:05:47 AM. Review of Patient 1’s clinical record indicated a Nurse Patient Missed Visit dated 4/23/22, indicated Missed visit electronically signed by RN 2 on 4/23/22 secondary to Patient refused SN visit, PT reports she only wants to be weighted by a digital scale and that she was transferred to another agency but does not know the name of the agency.” Review of the Skilled Nurse Discharge Summary dated 4/23/22, indicated patient was discharged to another agency, with DPCS documented as caregiver.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide digital scale, as ordered by the physician for one of 10 sampled patients ( Patient 9). This deficient practice had a potential in the the patient weight not monitored. Findings: During telephone interview with Patient 9 on 5/3/22, at 2:23 pm., and on 8/10/22, at 3 pm., she stated she only saw the SN one time which was on 4/5/22. Patient 9 stated she requested a digital scale due to her vision declining and called the HHA numerous times due to no skilled nurse visits only to be told she was refusing visit. Patient 9 stated she has never been contacted by the HHA since their first visit, she is homebound and has never refused visits. Patient 9 stated she never heard back from the HHA and she went to her physician to request another agency who could care for her. During the telephone interview the caregiver of Patient 9 stated, Patient 9 has never refused a visit and the caregiver gave staff her number to call due to Patient 9 being ill an unable to answered the phone. The PCG stated no one has visited Patient 9 since the first visit nor have they called her to make arrangements. The PCG stated Patient 9 has ever refused a skilled nurse visit and the skilled nurses just never came back. During a review of Patient 9’s clinical record, the document titled, “Outcome and Assessment Information Set(OASIS) and Plan of Care (POC)”, with the certification period from 4/5/2022 to 6/3//2022, indicated a start of care (SOC) date on 4/5/2022, with diagnosis that included malignant neoplasm of the stomach, unspecified, weight loss, unsteady gait and generalized weakness. The physician ordered Skill nursing visit one time a week for three weeks to assess/instruct patient and patient caregiver (PCG) diet/hydration to promote proper management of disease process, Assess Gastrointestinal status, monitor and record fluid intake/output, and check weights ever visit. During a telephone interview with the RN 1 on 4/26/22, at 3:16 p.m., she stated she did the initial assessment and Patient 1 was somewhat angry due to two missed visit prior to me coming. RN 1 stated, “ I may have dropped the ball. RN stated she was supposed to call the HHA after initial visit and request for follow-up visit with License Vocational Nurse (LVN) however, since she just restarted with this HHA she did not know she was supposed to sign off.” During another interview with RN 1 on 8/12/22 at 11:30 am., RN 1 stated she only saw Patient 9 one time which was the initial evaluation and completed a SBAR regarding Patient 9's need for a digital scale and her need for physical therapy due to her unsteady gait and generalized weakness. During a concurrent interview with the Administrator (ADM) and Director of Patient Care Services (DPCS) on 8/12/22 at 1:30 p.m., stated the Nurse who assessed Patient 9 did not call the office and put the patient on the schedule. The ADM stated, it was a communication failure with our staff. Review of the Report of incident form dated 4/25/22, completed by the DPCS, it indicated," Delay in starting SOC. Planned visits 1 time a week x 3 weeks with no follow up by SN who said she would be following patient."

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 interview and record review, the Home Health Agency (HHA) failed to coordinate care and services to meet the nutritional needs for 1 of 10 sampled patients ( Patient 9) This deficient practice resulted in Patient 9's needs were not addressed resulting for Patient 9 to contact her physician to be transferred to another HHA. Findings: During a Recertification survey/complaint investigation on 8/9/22 through 8/12/22, review of Patient 9’s clinical record, the document titled, “Outcome and Assessment Information Set(OASIS) and Plan of Care (POC)”, with the certification period from 4/5/2022 to 6/3//2022, indicated a start of care (SOC) date on 4/5/2022, with diagnosis that included malignant neoplasm of the stomach, unspecified, weight loss, unsteady gait and generalized weakness. The physician ordered Skill nursing visit one time a week for three weeks to assess/instruct patient and patient caregiver (PCG) diet/hydration to promote proper management of disease process, Assess Gastrointestinal status, monitor and record fluid intake/output, and check weights ever visit. During concurrent telephone interview with Patient 9 and her caregiver/family member on 8/12/22, at 12:23, they both stated Patient 9 only saw the SN (RN 1) one time which was on 4/5/22, and requested a digital scale due to her vision declining and called the HHA numerous times due to no skilled nurse visits only to be told she was refusing visit. Patient 9 and her caregiver/family member stated Patient 9 has never refused a visit and the caregiver gave staff her number to call due to Patient 9 being ill an unable to answered the phone at times. The PCG stated no other SN has visited Patient 9 since the first visit nor have they called Patient 9 back regarding no visits, to make arrangements for home visits or to follow up her complaint to the HHA regarding the need for a digital scale. Review of Patient 9's Clinical record indicated the HHA's form titled Nurse Patient Missed Visit dated 4/2/22 , by RN 3, indicated a missed visit /initial Evaluation delayed on 4/2/22 secondary to - form left blank. Review of Patient 9’s clinical record indicated a Nurse Patient Missed Visit dated 4/3/22, indicated Missed visit Initial evaluation delayed on 4/3/22 secondary to Patient refused visit since with family and asked for HHA to provide scale for patient to check her weight, RN 3 called DPCS to see if SN must have scale and was told No from DPCS who she will follow up in office tomorrow. Review of Patient 9’s clinical record indicated a Nurse Patient Missed Visit dated 4/15/22, indicated Missed visit by RN 1 on 4/15/22 secondary to Patient did not appear to be home for appointment (i.e. no answer). Review of Patient 9’s clinical record indicated a Nurse Patient Missed Visit dated 4/2/22, indicated Missed visit Initial evaluation delayed on 4/2/22 secondary to (form blank ) electronically signed by RN 3. Review of Patient 9’s clinical record indicated the HHA form “Nursing Visit Record” dated 4/20/22 Time In : 1:00 PM- Time Out 1:45 pm., Signed by Patient 1 on 4/26/22, at 10:07:31 AM and electronically signed by RN 1 on 4/26/22, at 10:05:47 AM. Review of Patient 9’s clinical record indicated a Nurse Patient Missed Visit dated 4/23/22, indicated Missed visit electronically signed by RN 2 on 4/23/22, secondary to Patient refused SN visit, PT reports she only wants to be weighted by a digital scale and that she was transferred to another agency but did not know the name of the agency.” Review of the Skilled Nurse Discharge Summary dated 4/23/22, indicated patient was discharged to another agency, with DPCS documented as caregiver. During a concurrent interview with the Administrator (ADM) and Director of Patient Care Services (DPCS) on 8/12//22, at 2: 30 p.m., in the kitchenette area of the HHA during the on-site complaint investigation stated the Nurse who assessed Patient 9 did not call the office and did not put the patient put on the schedule so the nurses did not have it on the schedule and that was how Patient 9 visits were missed. The ADM stated the Registered Nurses (RN) are the case managers and we tried to schedule a visit as soon as we found out. It was a communication failure with our staff.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency ( HHA) failed to ensure the nursing staff provided instructions or health teaching to the the patient's caregiver (PCG) to one of 10 sample patients (Patient 5). Patient 5 who was a diabetic and on insulin regimen was not taught regarding protein meal replacement that included shakes to drink for the patient. This deficient practice has the potential in putting the patient at risk to manifest high blood sugar levels that could affect the patient clinical status and well being. Findings: A review of Patient 5's record was reviewed. The forms titled, "Home Health Certification and Plan of Care" (POC), certification period from 6/26/22 to 8/24/2022, indicated the start of care (SOC) of 6/26/2022, with diagnoses of pressure ulcer of right lower back, stage 2, unspecified dementia without behavioral disturbances, age related physical debility , type 2 diabetic mellitus (high blood sugar). A home visit was conducted on 8/10/2022, with LVN1, and Patient 9's PCG. During a review of Patient 5's medications in the home indicated Patient 5 takes Insulin Glargine( diabetes medication) ( Lantus) 100 units/ML - unit of measure)subcutaneous 15 units every night , Metformin HCL (diabetic medication) 500 mg ( unit of measure) 1 tablet three times a day. The care giver brought out Boost protein shake for diabetic and Ensure Max, high protein shake that was not for diabetics. Both shakes were given to Patient 5 as a meal supplement. During an interview with the director of patient care services (DPCS) on 8/11/2022, she stated Patient 5 should not be drinking Ensure max due to the high sugar content and that would increase Patient 5's blood sugar. Review of the HHA's Policy and Procedure titled," Patient/Family Education" stipulates, " All Patients admitted to the Agency for care, treatment and/or services and/or family members shall be provided with appropriated education and training specific to needs identified during the initial and ongoing assessments, learning preferences and readiness to learn as appropriate to the care, treatment and/or services provided by the HHA. Patient/family education shall be documented in the patient's medical record by all disciplines providing education to the patient/family, using standardized teaching tools/formats when appropriate and available."

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 observation, interview, and record review, the home health agency (HHA) failed to screen visitors, field and office staffs for signs and symptoms of COVID-19 (an acute serious respiratory illness). This failure had the potential to spread infection. Findings: During an unannounced visit for the recertification survey of the home health agency on 8/9/22, at 11:15 a.m., observed there was no COVID-19 screening for visitors, office and field staff upon entrance of the home health agency (HHA). Healthcare personnel (HCP) were not wearing facial coverings inside the office. On 8/10/22 at 12:20 p.m., observed there was no COVID-19 screening for visitors, office and field staff upon entrance HHA. On 8/11/22 at 11:50 a.m., observed there was no COVID -19 screening for visitors, office and field staff upon entrance HHA. On 8/12/22 at 9:15 a.m., observed there was no COVID -19 screening for visitors, office and field staff upon entrance HHA. During an interview on 8/11/22 at 11:50 a.m., with the Director of patient care services (DPCS) stated the field staff should notify the agency if the patient is positive and had symptoms of Covid-19 and the office asks who is the assigned staff for the patient and notify the doctor. DPCS also stated they have the staff tested for Covid-19 when they present with signs and symptoms. DPCS stated there is no testing for office and field staff being done on a regular basis. A review of the document presented by the HHA that they follow titled " Interim Infection prevention and Control Recommendations for healthcare personnel During the COVID-19 Pandemic by the Centers for Disease Control (CDC) and Prevention As of 2/10/21. This interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States. New recommendations in this updated guidance are noted in the summary of changes above; all recommendations are organized in the following sections: Recommended infection prevention and control (IPC)practices fir routine healthcare delivery during the pandemic. Recommended IPC practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection. Screen and triage everyone entering a healthcare facility for signs and symptoms of COVID-19. Although screening of symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility. Establish a process to ensure everyone (Patients, healthcare personnel (HCP) and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 and that they are practicing source control. HCO should wear well fitting source control at all times while they are in a healthcare facility, including breakrooms and other spaces where they might encounter co-workers. Educate patients, visitors and HCP about the importance of performing hand hygiene, including immediately before and after any contact with their own cloth mask, face mask or respirator.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide infection control education and training for office and field staffs. This failure had the potential to spread infection and communicable disease to staff and patients Findings: During a concurrent interview and record review on 8/9/22, at 1:31 p.m., with the Director of Patient Care Services (DPCS) about their infection control education and training for field and office staffs, they could not provide written documentation for any education or In-service training for infection control held via telephone or video. A review of the HHA's document titled "Infection control Signs and Symptoms" dated 1/20/2021 indicated tele and tele visional communication during this COVID pandemic. No in-person in-services shall be conducted. A review of the HHA's policy titled "Aseptic Practices" effective 6/1/2017 indicated the HHA staff receive training in aseptic techniques before beginning patient care at the time of orientation, annually thereafter and as needed.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed meet the Conditions of Participations for Skilled Professional services, as follows: 1. Failure to ensure glucometers (blood sugar machine) were calibrated (the act or process of marking a measuring instrument with the necessary graduations, the resulting markings or settings) for 2 out of 5 sampled patients, Patient 1 and Patient 2 and the current medication were listed in the patient's medication profile for 1 of 5 sampled patients, (Patient 1). (Refer to G 704). 2. Failure to clarify with the physician any changes or additions in the patients' plan of care, for 2 of 5 sampled patients, (Patient 1 and Patient 2). (G 718) 3. Failure to ensure performance evaluations were conducted for the five of 5 new employees who were directly involved in the provision of the care and services to the patients under the agency's care. (Refer to G 772). The cumulative effect of this deficient practice resulted in the failure of the HHA to deliver statutorily mandated compliance of the Federal regulations for Skilled Professional Services to ensure provision of highest quality patient care and services. .

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observations, interviews and record reviews, the home health agency (HHA) failed to: 1. Ensure glucometers (blood sugar machine) were calibrated (the act or process of marking a measuring instrument with the necessary graduations, the resulting markings or settings) for 2 out of 5 sampled patients, Patient 1 and Patient 2. 2. Ensure the current medications were listed in the patient's medication profile for 1 of 5 sampled patients, (Patient 1). This deficient practice had the potential for poor quality nursing services that can affect the health and safety of all the patients under the agency's care. 1. A review of Patient 1's Patient Profile Information indicated, a start of care (SOC) date of 7/15/22, with a certification period of 7/15/22 to 9/12/22. Patient 1's diagnosis included type 2 diabetes (is a chronic condition where the body does not produce insulin which regulates the blood sugar) with skin ulcer (an open sore in the skin). A home visit was conducted on 8/10/22 at 10:15 a.m., Licensed Vocational Nurse 1(LVN 1). Patient 1 was observed sitting in the dining area, alert and oriented to name, place, and time, not in any respiratory distress. During the observation, LVN 1 did not calibrate (the act or process of marking a measuring instrument with the necessary graduations, the resulting markings or settings) Patient 1’s glucometer machine (a machine that checks blood sugar). LVN 1 stated “Patient checks her own blood sugar with her own machine. When asked if it was regularly calibrated, LVN 1 stated “I do not calibrate her glucometer”. During wound care, Patient 1 was observed closed her eyes while LVN 1 started her wound care. When asked if she was in pain, Patient 1 stated that she takes a combination of over-the-counter Advil (pain medicine) and Tylenol (pain medicine) together when pain becomes unbearable. A review of the medication profile did not indicate Advil and Tylenol were listed in the current medication profile. LVN 1 stated she reviews Patient 1’s medication at least once a week. LVN 1 further stated that she asks Patient 1 for any new orders from her doctors and LVN writes an order in Patient 1’s electronic medical record. 2. A review of Patient 2's Patient Profile Information indicated, a SOC date of 6/17/22, with a certification period of 6/17/22 to 8/15/22. Patient 2 is an 85-year-old male with diagnosis that included chronic respiratory failure (is a long-term condition that happens when your lungs cannot get enough oxygen into your blood) with hypoxia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin) and diabetes. A home visit was conducted on 8/10/2022 at 11:45 a.m. with LVN 3. Patient 2 was observed sitting in the living room, alert and oriented to name, place, and time. During the observation, LVN 3 did not calibrate Patient 2’s glucometer. When asked regarding when she would calibrate Patient 1's glucometer, LVN 3 stated “We were not taught to calibrate the patients machine on our visits.” LVN 3 stated Patient 2 checks his own blood sugar with his own machine when Patient 2 “feels different.” LVN 3 stated she reviews Patient 2’s medication once a week if there is anything new. A review of the HHA’s policy titled “Glucose Monitor Quality Control”, revised on 9/1/2017, indicated to ensure accurate blood glucose testing of the HHA’s patients, to maintain quality control checks of glucose monitors in compliance with applicable laws, regulations, standards and guidelines. HHA nurses who have been determined competent to perform glucose monitor quality control checks will perform quality control checks of glucose monitors each day prior to patient testing. Perform check strip quality test, low control quality test and high control quality test according to the manufacturer’s recommendations and/or instructions. A review of the HHA’s document titled, “Job Description/Performance Evaluation Licensed Practical Nurse(LPN)/Licensed Vocational Nurse(LVN)” dated, 3/1/2017 indicated demonstrates competency in the following areas: Provides skilled nursing in the home as ordered on the plan of treatment and nursing care plan. Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. Professional requirements: adheres to legal practice standards, including federal, state and local regulations and standards. Assures continued competency by maintaining and updating professional performance, knowledge, and skills.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to clarify with the physician any changes or additions in the patients' plan of care, for 2 of 5 sampled patients, (Patient 1 and Patient 2). This deficient practice had the potential to affect the quality of care and services provided to the patients under the agency's care 1. On 8/10/2022 at 10:15 a.m., a home visit was conducted at Patient 1's residence with Licensed Vocational Nurse (LVN) 1. Patient 1 was observed sitting in the dining area, was alert and oriented to name, place, and time. On 8/10/2022 at 10:30 a.m., Patient 1 was observed closed her eyes when LVN 1 started the wound care. LVN 1 stated there was a change on wound care orders. LVN 1 stated Patient 1 gave her the written orders from the doctor who wrote it in Patient 1’s electronic medical record. A review of Patient 1's Patient Profile Information indicated, a start of care (SOC) date of 7/15/22 for the certification period of 7/15/22 to 9/12/22, with diagnosis that included type 2 diabetes (abnormal blood sugar levels) with skin ulcer (an open sore in the skin). A review of Patient 1’s plan of care dated 7/15/22 indicated wound treatment to the left lower leg ulcer cleanse with normal saline, 1:1 mix hydrogel with bacitracin (topical antibiotic), apply to all sloughing area (a mass of dead skin around a wound or ulcer) of the wound with cotton tip applicator, apply 4x4 (gauze), wrap leg in conforming wrap loosely to preserve blood circulation daily, elevate both legs with heels in air. Patient caregiver to do wound care on weekends. During an interview on 8/10/2022 at 10:30 a.m., LVN 1 stated there was a change on Patient 1's wound care orders to change the dressing with Aquacel AG (a waterproof barrier to protect skin and allow bathing, an antimicrobial protection), with hydrogel (a type of dressing) to wound bed, cover with multilayer gauze and secure with tape. LVN 1 stated that Patient 1 usually tells me of the new order and then “I place the new order in her electronic chart.” A review of Patient 1’s electronic medical record did not indicate a written communication from the physician that the previous order was discontinued or changed. During an interview on 8/11/2022 at 12:25 p.m., the Director of Patient Care Services (DPCS) stated, "the way we do wound care is that the patients give the prescription to the nurse and the nurse is supposed to send the order to the office and we do the updates on the plan of care. They don’t verify medication orders. If the physician has a signature on the prescription, we add it to the plan of care." 2. A home visit was conducted on 8/10/2022 at 11:45 a.m. at Patient 2's residence. Patient 2 was observed sitting in the living room, was alert and oriented to name, place, and time. During the observation, Patient 2 stated concerns with his blood work that were ordered from his oncologist, nephrologist, and cardiologist, that “I need to pay $75.00 for my blood work for laboratory to come here at home". When LVN 3 was asked if the HHA knew about this, LVN 3 stated “No, I did not know of any blood work that needs to be done.” LVN 3 stated that the HHA is also contracted with a laboratory company. LVNs can perform the blood work if there were orders. When asked, Patient 2 stated “I did not know that the home health agency has laboratory.” A review of Patient 2's Patient Profile Information indicated a SOC date of 6/17/22, for certification period 6/17/22 to 8/15/22, with diagnoses that included chronic respiratory failure (difficulty breathing) with hypoxia (low levels of oxygen in your system) and diabetes. During the interview on 8/11/2022 at 12:25 p.m., the DPCS stated, “we do not communicate to the other doctors other than the primary doctor who referred them to home health but if the patient expressed the need for help that they need, then we can coordinate with them.” A review of Patient 2’s electronic medical record did not indicate any written communication from LVN 3 to the cardiologist, nephrologist and or the oncologist regarding the laboratory test orders. A review of the HHA’s policy titled, “telephone/verbal orders”, dated 4/1/2017 indicated all orders are renewed or updated to reflect changes in care, treatment and or services being provided. Changes in the patients physical or psychosocial condition, the patient’s response to care, treatment and or services, the patient’s outcome related to care, treatment and/or services, changes in diagnosis, treatment (including procedures and medications) and equipment. Physician telephone or verbal orders are accepted by qualified staff and submitted to the physician for his/her signature. Original and/or new/updated orders are transcribed onto a physician order form or a plan of treatment form as appropriate, mailed, faxed to the physician for signature. A review of the HHA’s policy titled, “Assessment-Nursing”, dated 5/1/2017, indicated to provide each patient regardless of payment source with a comprehensive assessment that accurately identifies the patient’s needs for care, treatment and /or services within an appropriate time frame, as outlined by Federal regulatory requirements, to determine the patient’s current needs for continuing care, treatment and or services, including medical, nursing, rehabilitative, social and discharge planning, as well as his/her changing needs, to ensure that the patient’s current needs and /or problems are continuously evaluated and the care, treatment and or services provided are adjusted accordingly. It also indicated, the patient /family shall be evaluated for knowledge of and instructed about the patient’s condition/disease process, proposed care, potential benefits and effects and unanticipated outcomes of the care, treatment or services to be provided, and costs, if any to be borne by the patient/family for care, treatment or services.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure performance evaluations were conducted for the five of 5 new employees who were directly involved in the provision of the care and services to the patients under the agency's care. This deficient practice had the potential that staffs were unqualified staffs with skills necessary for an effective management and the provision of quality care to meet their patient needs. A review of the five employee files on 8/12/2022 at 12:04 p.m., indicated the home health agency did not have a completed performance evaluations for the following employees: 1. New Director of Patient Care Services, with date hired on 1/11/22, had no application for employment, no physical assessment, and the performance evaluation form was blank. 2. The Director of Patient Care Services designee, with date hired on 5/29/12 had no performance evaluation in her employee file file and no physical assessment. 3. Registered Nurse 1, with a contracted of 4/1/22, had no documented evidence of orientation to the HHA, no physical assessment and no performance evaluation. 4. Licensed Vocational Nurse 2, with date hired on 10/5/12, the performance evaluation dated 2/4/22, was not signed/dated by the DPCS and not signed by staff. There was no physical examination in the employee file. 5. The Administrator, did not have an employee file, however an employee file was created on 8/12/22. There was no performance evaluation, application for employment or physical examination. During an interview on 8/12/2022 at 11:40 a.m. with the Administrator on notifying the Department of Public Health regarding the newly hired Director of Patient Care Services, she stated she was in training and was not ready to take over the role so they have not informed the Department.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the governing body failed to assume full legal authority and responsibility for the overall management and operation of the HHA. This deficient practice has the potential risk to result in the substandard quality of care that could affect the health and safety of the patients. During the recertification survey on 8/9/2022 to 8/12/2022, the Administrator was unable to provide evidence that a governing body exists to address the functioning hospice operations. and QAPI program. During an interview with the Director of Patient Care Services (DPCS) on 8/9/2022 at 11:50 a.m., the DPCS stated that the Administrator was on vacation and was not available. During a review of the Performance Improvement program and the QAPI on 8/12/22 indicated QAPI and PIP lesson plans were empty, the home health agency personnel and the Governing body members could not present documented evidence and were not conducting their meetings for the past year.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Administrator failed assume full responsibilty for the day to day operation of the Home Health agency. This deficient practice resulted in seven (7) Conditions of Participation not met during the recertification survey. During the recertification survey on 8/9/2022 through 8/12/2022,the home health agency (HHA) failed to investigate, follow-up and document the outcome of patient complaints in a timely manner. The HHA failed to ensure coordination of services were provided for 2 or 10 sampled patients. The Administrator failed to ensure employees meet the qualification, employee files current with Performance evaluations, Failed to ensure the Emergency preparedness was current ,and the Infection control protocol . Failed to ensure the physician were notified of missed visit and the need for scale. Medications were updated in the patients medication profiles and failed to ensure staff provided care per physicians order. The administrator failed to be responsible for the day to day operation of the HHA. These deficient practices resulted to seven ( 7) Conditions of Participation not met during the Recertification survey. CFR 484.102- Emergency Preparedness Program CFR 484.60- Care planning, Coordination of Services, and Quality of Care CRF 484.70- Infection Control CFR 484.65- Quality Assessment and Performance Improvement CFR 484.75-Skilled Professional Services CFR 484.105-Organization and Administration of Services CFR 484.110- Clinical Records