Every finding on record at Port City Operating Company, LLC

The following reflects the findings of the California Department of Public Health during an EMERGENCY PREPAREDNESS SURVEY conducted 5/13/25 through 5/15/25. The agency reported 1199 unduplicated annual admissions. The sample size was 18, and 7 home visits were conducted. The home health agency was found to be in compliance with 42 CFR, part 418.102 for Emergency Preparedness.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 5/13/25 through 5/15/25. The agency reported 1199 unduplicated annual admissions. The sample size was 18, and 7 home visits were conducted.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to provide written notices in a language that patient understood for one out of eighteen sampled patients (Patient 5), when Patient 5 who have limited English proficiency, was not provided written notice in her primary and preferred language. This deficient practice violated Patient 5’s right to be informed of her rights in an understandable language and had the potential for Patient 5 to lack knowledge about the exercise of her rights while receiving services from the agency. Findings: Review of “Patient Information Report” indicated Patient 5’s preferred language was Spanish. During a concurrent home visit observation, interview, and record review on 5/14/25, at 1:03PM, Licensed Nurse (LN) 1 stated Patient 5 primarily spoke Spanish and spoke limited English. Patient 2 was observed to be alert, oriented and spoke limited English. There was an agency folder in Patient 2’s room containing information including patient rights and responsibilities, agency contact, emergency plan, complaint contact, Department contact. Patient 2 stated she could not read English. LN 1 stated agency had information folders in Spanish to provide to the patients. Patient 2 stated agency did not provide her an information folder in Spanish and would like to have a Spanish folder. Patient 2 added she liked to read. LN 2 stated Patient 2 should have given an information folder in Spanish when readmitted to the agency in March 2025. During a concurrent interview and record review on 5/15/25, at 12:14 PM, the Manager of Clinical Services (MCS) stated agency should provide a folder with information to the patient in their primary language upon admission so that patient could understand their rights and the treatment/services they were receiving. The MCS confirmed Patient 2’s “HOME HEALTH ADMISSION CONSENT” signed on 3/28/25 was written in English, a language which Patient 2 could not read. The MCS stated Patient 2 should have been provided consent form written in her primary language Spanish. Review of agency policy titled “Bill of Rights and Responsibilities” revised 2/24/23, indicated, “…Each patient, upon admission is given information regarding the Patient Bill of Rights and responsibilities in language the patient can reasonably be expected to understand, which includes…Be informed, both verbally and in writing, in advance of care being provided…”

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 agency failed to ensure two (2) of eighteen sampled patients (Patient 1 and Patient 7) received all services outlined in the plan of care (POC - a comprehensive, individualized document that outlined the patients’ specific needs, goals, and the interventions required to achieve those goals) when, Patient 1 was not seen by the Home Health Aid (HHA) in the number of times ordered by the physician, and 2. Patient 7 did not receive skilled nurse visits as per physician order. These failures could have resulted in, Patient 1 acquiring an infection and/or a decline in overall health and Patient 7 not receiving needed care and services. 2. Review of “Patient Information Report” indicated Patient 7’s diagnoses included hypertensive heart (heart disease from unmanaged high blood pressure for long time) and chronic kidney disease with heart failure, diabetes mellitus (high blood sugar levels). Review of Patient 7’s physician order dated 1/24/25, indicated, “…Order Description: ADDITIONAL RN [Registered Nurse] HOME VISITS NEEDED FOR CONTINUED EDUCATION AND ASSESSMENT…SN [Skilled Nurse] EFFECTIVE 01/26/2025 4WK1[four times a week for one week],1WK4[once a week for four weeks] …” During a concurrent interview and record review on 5/13/25, at 3:32pm, Resident 7’s RN home visit record was reviewed with the Director of Patient Care Services (DPCS). The DPCS confirmed Patient 7 received only one RN home visit the week of 1/26/25 on 1/31/25. The DPCS verified physician ordered to provide four SN visits to Patient 7 the week of 1/26/25. The DPCS stated there was no documentation indicating the reason for not scheduling or providing four nurse visits as ordered. The DPCS stated Patient 7 should have received four nurse visits as ordered to provide the care he needed. The DPCS stated if a patient did not receive the care and services as ordered then it would impact the patient negatively. Review of a facility policy titled “Plan of Care and Physician and Allowed Practitioner Orders” revised 3/5/24, indicated, “…All care and services provided are according to our current physician or allowed practitioners orders…” Findings: 1.During a review of Patient 1’s clinical record titled, “Patient Information” (a document that contained Patient 1’s demographic information), the record indicated Patient 1’s diagnosis included, multiple myeloma (cancer), paraplegia (unable to move legs), neuromuscular dysfunction of the bladder (disease that controlled the ability to pass urine), and the use of a urinary device (indwelling urinary catheter [a small plastic tube placed in the bladder to drain urine]). A review of Patient 1’s clinical record titled, “Home Heath Certification and Plan of Care”, dated 2/23/25 to 4/23/25, the record indicated HHA (Home Health Aid) services were ordered by the physician for assistance with Patient 1’s personal care, hygiene and activities of daily living (brush teeth, showers, comb hair). The frequency and duration of visits were 2WK3 (two times a week for 3 weeks) and then 1WK1 (once a week for one week). A review of Patient 1’s clinical record titled, “Order Description”, dated 3/17/25, by the Physician (PHYS), the order indicated HHA visits were to take place twice weekly for the remainder of the certification period as the caregiver needed respite care (temporary relief for family caregivers, that allowed them to take a break from their caregiving responsibilities). A review of Patient 1’s clinical record titled “Aid Care Plan Report”, dated 2/23/25, indicated the HHA was ordered to assist Patient 1 with turning and repositioning in bed, assist with passive range of motion (ROM – the HHA did all the effort to move the joints) to both legs, provide a sponge bath, wash and comb hair, provide foot care, nail care, skin care, urinary catheter care, and perineal care, assist with transfers (move from one location to another i.e. bed to a chair), and assist with dressing. During a concurrent interview and record review on 5/15/25, at 2:30 p.m., with the Manager of Clinical Services (MCS), Patient 1’s clinical record titled, “Client Coordination Note Report”, dated 3/7/25, 3/14/25, 3/28/25, and 4/11/25, and the agency’s Policy and Procedure (P&P) tiled, “Missed Visit or Shift”, dated 3/21/23, were reviewed. The records indicated, -“Client Coordination Note Report”, dated 3/7/25, indicated a missed HHA visit occurred on 3/7/25 because the HHA was sick. The note did not indicate the visit was rescheduled. -“Client Coordination Note Report”, dated 3/14/25, indicated a missed HHA visit occurred on 3/13/25 because Patient 1’s house had a power outage. The note did not indicate the visit was rescheduled. -“Client Coordination Note Report”, dated 3/28/25, indicated a missed HHA visit occurred on 3/28/25. An explication for the missed visit was not provided and the note did not indicate the visit was rescheduled. -“Client Coordination Note Report”, dated 4/11/25, indicated a missed HHA visit occurred on 4/11/25. An explication for the missed visit was not provided and the note did not indicate the visit was rescheduled. The concurrent interview and record review with the MCS continued with the review of the P&P titled, "Missed Visit or Shift”. The P&P indicated, “… In the event that a patient or an employee cancels a scheduled visit ordered by the physician … the visit will be rescheduled …” The MCS stated when the HHA was not able to visit Patient 1 (per the physician's order), a RN could have gone out to provide care to Patient 1. The MCS stated there was no explication documented for the missed visits on 3/28/25 and 4/11/25 and there were no attempts to reschedule the missed visits for 3/7/25, 3/13/25, 3/28/25, and 4/11/25. The MCS stated the HHA visits included providing urinary catheter care which was an intervention to decrease Patient 1’s risk of acquiring Urinary Tract Infection (UTI – infection of the ureters or bladder). The MCS stated the missed HHA visits placed Patient 1 at risk for infection and decline in overall health. The MCS acknowledged the P&P was not followed.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure two (2) of eighteen sampled patients (Patient 1 and Patient 3) received their initial physical assessment within the required timeframe when, 1. Patient 1 was not seen by a Registered Nurse (RN) within 48 hours of the referral date (the date the agency received the information about the patients’ need for home health services); and, 2. Patient 3 was not seen by an RN within 48 hours of the referral date. These failures put Patient 1 at increased risk for acquiring a Urinary Tract Infection (UTI – infection of the urinary system) related to the delayed assessment of Patient 1’s use of an indwelling urinary catheter (plastic tube placed in the bladder used to drain urine – which when not frequently monitored, could cause UTIs) and other ordered services were not provided. Additionally, these failures placed Patient 3 at increased risk of uncontrolled symptoms of diabetes (the body’s inability to regulate blood sugar levels) including dizziness, confusion, and possibly a diabetic coma (unconsciousness caused by dangerously high or low blood sugar levels) and other complications related to her multiple medical diagnoses. 2. A review of Patient 3’s “Patient Information Report”, undated, indicated diagnoses which included diabetes with hyperglycemia (high blood sugar levels), diabetic neuropathy (nerve damage that can result from having diabetes), diabetic autonomic neuropathy (a serious complication of diabetes where nerve damage affects involuntary bodily functions), retention of urine (inability to completely empty the bladder), and gastroparesis (the stomach empties too slowly, leading to digestive problems). Further review of Patient 3’s “Patient Information Report” indicated Patient 3 was referred to (home health agency name) on 2/8/25. A review of Patient 3’s “Client Coordination Note Report”, dated 2/10/25, indicated, “…THE PATIENT (Patient 3) CALLED BACK AND AGREED FOR THE RN SOC TO BE ON WEDS (Wednesday). I WILL LET (name redacted) KNOW TO GET A DELAY OF CARE…” A review of Patient 3’s “Episode Summary Report”, undated, indicated a SOC date of 2/12/25, four days after the original referral date. The report indicated Patient 3 was to receive care and services from nursing (RN), physical therapy (exercises, education, and devices to improve your ability to move), and occupational therapy (exercises and other strategies to help improve your ability to perform daily activities, such as getting dressed, bathing, or dining.) The report included, “…NURSE TO EVALUATE AND DEVELOP PLAN OF CARE…ASSESS/EVALUATE ANY CONDITIONS THAT PRESENT THEMSELVES AND THAT WILL IMPACT THE PLAN OF CARE…TO IDENTIFY CHANGES AND INTERVENE TO MINIMIZE COMPLICATIONS…” During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 5/13/25 at 2:42 p.m. of Patient 3’s medical record, the DPCS confirmed Patient 3’s SOC date, 2/12/25, was four days after the referral date. The DPCS confirmed a Patient’s SOC date should be no more than forty-eight hours after the referral date. During an interview on 5/15/25 at 4 p.m., the MCS stated the risks of a late SOC date to any patient would be worsening medical conditions, emergency room visits, and even death. Findings: During a review of Patient 1’s clinical record titled, “Patient Information” (a document that contained Patient 1’s demographic information), the record indicated Patient 1’s diagnosis included, multiple myeloma (cancer), paraplegia (unable to move legs), neuromuscular dysfunction of the bladder (a disease that made it difficult to pass urine), and the use of an indwelling urinary catheter (insertion of a plastic tube into the bladder to drain urine) device. The referral date was on 2/18/25 for Patient 1 to begin home health services. A review of Patient 1’s clinical record titled, “Home Health Certification and Plan of Care”, dated 2/23/25 to 4/23/25, indicated the Start of Care (SOC – the date the Registered Nurse [RN] assessed Patient 1) was on 2/23/25. A review of Patient 1’s clinical record titled, “Client Coordination Note Report”, dated 2/20/25, indicated, “The patient returned my call and agreed for the RN SOC to be on Sunday 2/23…” A review of Patient 1’s clinical record titled, “Home Health Updated Plan of Care Report”, dated 3/19/25, by the Physician (PHYS), the record indicated the PHYS’s order for Skilled Nursing Services included, - observe and assess neurological system (the brain, spinal cord, and a complex network of nerves), identify changes and intervene to minimize complications, and provide skilled teaching related to nutrition, medication regimen, and activities. - observe and assess pain, effectiveness of pain management, and review medications -focus on identified need for high-risk medication intervention - assess and monitor anticoagulant therapy (blood thinning medication) -observe and assess genitourinary (urinary system) status and intervene to minimize complications - instruct patient/caregiver in indwelling urinary catheter management including care, and signs and symptoms of complications and provide perineal care (cleaning the area between the anus and the vagina or penis) - skilled nurse to insert a new indwelling urinary catheter monthly and as needed -observe and assess skin status, intervene to minimize complications, and provide teaching related to altered skin integrity -observe and assess cardiovascular (heart) system to identify changes, intervene to minimize complications, and promote self-care management - observe and assess complications related to multiple myeloma and provide education regarding nutrition, medication regimen, and permitted activities During an observation of Patient 1 on 5/14/25, at 9:30 a.m., Patient 1 was noted to have an indwelling urinary catheter in place with urine in the collection bag. During a concurrent interview and record review on 5/15/25, at 2:30 p.m., with the Manager of Clinical Services (MCS), Patient 1’s plan of care for the certification period of 2/23/25 to 4/23/25 and the agency’s Policy and Procedure (P&P) titled, “Admission for Care and Services”, dated 1/13/25, were reviewed. Patient 1’s plan of care for the certification period of 2/23/25 to 4/23/25, indicated Patient 1 was referred to the agency on 2/18/25 and the SOC was on 2/23/25. The P&P titled, “Admission for Care and Services”, indicated, “… If the patient is accepted, the initial assessment will be completed within 48 hours of referral …” The MCS stated Patient 1 should have been assessed by the RN within 48 hours of the referral date. The MCS stated there was no explanation in the clinical record as to why Patient 1’s SOC was delayed. The MCS stated it was important to start Patient 1’s SOC within 48 hours because she was at an increased risk for infection due to the indwelling urinary catheter device and because of her poor health status. The MCS acknowledged the P&P was not followed.

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 one of eighteen sampled patients (Patient 5’s) medication profile was reviewed and updated, when Patient 5’s medication report did not include all the medications patient was currently taking. This failure had the potential risk for medication errors, ineffective drug therapy, unsafe medication interactions, significant side effects and inability to accurately assess Patient 5's response to the medications. Findings: Review of Patient 5’s clinical record titled “HOME HEALTH CERTIFICATION AND PLAN OF CARE” with Start of Care (SOC) date 3/28/25, indicated Patient 5 had multiple diagnoses including pyonephrosis (a rare and serious kidney infection), diabetes mellitus (abnormal blood sugar levels), hypertension (high blood pressure), problems related to health literacy. Further clinical record review indicated, “…SKILLED NURSE FOR INSTRUCTIONS/REINFORCEMENT OF/MANAGEMENT OF DIABETES TO INCLUDE DIET, SKIN CARE, MEDICATION MANAGEMENT…SKILLED NURSE TO PROVIDE SKILLED TEACHING TO PATIENT/CARGIVER OF HYPERTENSION TO INCLUDE MEDICATION MANAGEMENT…SKILLED NURSE FOR OBSERVATION/ASSESSMENT OF PAIN, EFFECTIVENESS OF PAIN MANAGEMENT INCLUDING MEDICATION REVIEW…SKILLED NURSE TO FOCUS ON IDENTIFIED NEED FOR HIGH RISK MEDICATION INTERVENTION…” During a concurrent home visit observation and interview on 5/14/25 at 1:03 pm with Licensed Nurse (LN) 1, Patient 5’s medications were compared with agency’s “Client Medication Report”. Patient 5 stated she had been taking Allegra for about 15 days for her allergies, ketotifen fumarate (allergy eye drops) for 3 months as prescribed by her primary care provider(PCP), Vitamin D3 for about 2-3 months as prescribed by her PCP after checked her labs, Tums (used to treat heart burn) for about one month and had been using fluocinonide(topical medication used on the skin to reduce swelling, redness, itching, and allergic reactions) along with Clotrimazole/Betamethasone/Dipropionate(a topical medication used to treat fungal skin infections) for her Psoriasis (a chronic skin condition where skin cells multiply too quickly, causing red, itchy, and scaly patches) for 3 years and was last prescribed by her PCP about 4 months ago. LN 1 confirmed these medications were not listed in Patient 5’s agency medication report. LN 1 confirmed “Client Medication Report” indicated Patient 5 was taking ferrous sulfate (iron supplement) twice a day whereas Patient 5 stated she had been taking ferrous sulfate 3 times a day as changed by her PCP 3 weeks ago. LN 1 confirmed “Client Medication Report” indicated Patient 5 was taking Omeprazole (medication used to treat heartburn) whereas Patient 5 stated she stopped using it about a month ago since it was not helping and her PCP changed it to Tums. LN 1 stated medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) should be done at every visit. LN 1 stated she visited Patient 5 a day before on 5/13/25. LN 1 added she did not do a thorough medication reconciliation and just asked Patient 5 if there were any changes to her medications. Review of Patient 5’s home visits record for certification period of 3/28/25 to 5/26/25 indicated, Patient 5 received 13 skilled nurse visits since start of care 3/28/25. During an interview on 5/15/25, at 12:14PM, the Manager of Clinical Services (MCS) stated staff was supposed to ask the patient for any medication changes or updates during every visit. The MCS stated patient medication report was reviewed and updated at SOC, Resumption of Care, recertification and any time changes made to the medications including new medications. The MCS verified Patient 5 was prescribed a new medication on 5/9/25 and a thorough medication reconciliation should have been completed then. The MCS confirmed Patient 5’s medication report should have been reviewed and updated to include all the medications Patient 5 was taking. An agency provided document titled “Focus on Care” dated Dec. 2023, indicated, “…Medication Reconciliation the Accreditation Commission for Health Care (ACHC) requires a review of all medications the patient is currently using, both prescription and non-prescription…Required Medication profile Contents: A medication profile includes, but is not limited to: All current medications…When is Medication reconciliation completed? Start of care, Resumption of Care, recertification, Discharge, and with newly ordered medications…THE MEDICATION PROFILE IN THE HOME MUST MATCH THE MEDICATION PROFILE IN THE ELECTRONIC MEDICAL RECORD SYSTEM. BOTH MUST BE UP-TO-DATE WITH EVERY VISIT…” An agency policy titled “Medication profile” revised 1/21/25, indicated, “…The medication profile will be updated at resumption of care, recertification, at discharge, and with any medication changes…During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient, family and/or caregiver; as well as, other clinicians understand the medication regime. This includes, but not limited to, using the medication profile for: Evaluation of the use of the drugs in the home setting, teaching the purpose of medication, dosages, routes, administration times, side effects and contradictions…”

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 follow standard infection control and prevention measures for one of eighteen sampled patients (Patient 6) when Licensed Nurse 2 (LN 2) did not change gloves and perform hand hygiene during Patient 6’s wound care. This deficient practice placed Patient 6 at increased risk of infection. Findings: Review of “Patient Information Report” indicated Patient 6 was admitted to the agency with multiple diagnoses including diabetes mellitus (abnormal blood sugar levels) with foot ulcer. During an observation on 5/14/25 at 12:05 PM, in Patient 6's home, LN 2 removed old dressing from Patient 6’s right toes, cleaned 2nd and 3rd toe wounds, applied treatment, and placed new dressing. LN 2 used the same pair of gloves throughout the procedure. LN 2 did not change gloves and perform hand hygiene after removed old dressing and before cleaning the wounds, applying treatment, and new dressing. During an interview on 5/14/25 at 12:40 PM, LN 2 confirmed he did not change his gloves and perform hand hygiene when removed old dressing and before cleaning wounds, applying treatment and new dressing during Patient 6’s right toes’ wound care. During an interview on 5/15/25, at 12:14 PM, the Manager of Clinical Services (MCS) stated staff should perform hand hygiene and change gloves after removing old dressing and before applying treatment and new dressing to prevent the risk of transmission of infection. Review of the agency policy titled “Application of Non-Sterile Dry Dressing” revised 9/6/22, indicated, “…Gently remove and discard soiled dressings in a plastic bag. Remove non-sterile gloves and discard. Perform hand hygiene. Don non-sterile gloves…Cleanse and dry the skin/wound…Apply ointment or other medication to the skin/wound, as applicable. Apply dressing…”

The following reflects the findings of the California Department of Public Health during an EMERGENCY PREPAREDNESS SURVEY conducted 8/23/22 through 8/25/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 43247 HFEN, 17069 HFEN, 38834 HFEN, 34980 HFEN, 40019 The agency reported 1290 unduplicated annual admissions. The sample size was 17 patients and 7 home visits were conducted.

The following reflects the findings of the California Department of Public Health during a Federal Recertification Survey conducted 8/23/22 through 8/25/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 43247 HFEN, 17069 HFEN, 38834 HFEN, 34980 HFEN, 40019 The agency reported 1290 unduplicated annual admissions. The sample size was 17 patients and 7 home visits were conducted.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, staff interview and agency document review, the agency failed to ensure services were provided as ordered on the Plan of Care (POC) for 4 of 17 sampled patients (Patient 4, Patient 9, Patient 10, and Patient 14). These failures had the potential for unmet needs. A review of Patient 9's clinical record indicated a SOC date of 5/20/22 for after care following a surgery for implanting a pacemaker. Patient 9's history and physical and diagnosis indicated that the patient had history of falls. A review of Patient 9's POC from 5/20/22 to 7/18/22, indicated Physical Therapy services were ordered for one time a week for 1 week effective the week of 5/22/22. During a concurrent interview and record review on 8/24/22, commencing at 1:30 p.m., the Director of Home Health (DHH) acknowledged that Patient 9's clinical records did not contain any documented evidence that a PT visit was made the week of 5/22/22. The DHH was not able to find any coordination notes to explain why Patient 9's PT visit did not happen until a week later on 6/2/22. The DHH stated, "I don't see any PT visits plotted for the week of 5/22/22. No explanation for the delay. I don't see any notification of the physician. The DHH stated her expectation was that if the visit was not done for some reason, the clinician should have notified the clinical manager and physician, but it did not happen." A review of the agency's policy titled, "Missed Visit or Shift," revised 2/22, indicated that if the visit was missed for any reason, the clinician should attempt to reschedule it for the same week to make sure the physician ordered services and frequencies were maintained. The policy indicated, "The clinician, Clinical Manager, and Supervisor will be notified ...when a visit ...is missed...If physician ...ordered frequency cannot be met, a Missed Visit Notification coordination note will be completed in the Patient Medical Record and the physician ...will be notified." A review of Patient 14's Home Health Certification and Plan of Care (POC), for certification period 7/24/22 to 9/21/22, indicated Patient 14 had a Start of Care (SOC) with the Home Health Agency on 7/24/22 for multiple diagnoses including cellulitis (skin infection) of left lower limb, left medial (towards the center of the body) foot ulcer (an open sore), heart failure (heart does not pump as well as it should), and chronic kidney disease (loss of kidney function). The POC indicated Patient 14 had orders for Skilled Nursing (SN) 5 times a week for 1 week, then 2 times a week for 1 week, and then 1 time a week for 7 weeks. A review of Patient 14's "Calendar Schedule" for the week of 7/24/22 to 7/30/22, indicated Patient 14 had SN visits on 7/24/22, 7/25/22, 7/27/22, and 7/30/22. A visit was scheduled for 7/28/22, but was not done as indicated on the "Calendar Schedule" by green color coding. During a concurent interview and record review on 8/23/22 at 2:20 p.m. with RN Supervisor 2 (RNS 2), RNS 2 stated that Patient 14 had a SN visit scheduled on 7/28/22, but visit was not documented that it was done. RNS 2 acknowledged that it was not documented why the visit was missed. RNS 2 stated, "Don't know why the missed visit was not documented." The RNS 2 acknowledged that Patient 14 received only 4 SN visits that week, instead of 5 that were ordered according to the POC. A review of the home health agency's policy titled "Plan of Care and Physician and Allowed Practitioner Orders," revised 4/15/22, indicated "...All care and services provided are according to current physician or allowed practitioner's orders..." A review of the home health agency's policy titled "Missed Visit or Shift," revised 2/16/22, indicated "...If the physician or allowed practitioner ordered frequency cannot be met, a Missed Visit Notification coordination note will be completed in the Patient Medical Record and the physician and if indicated, allowed practitioner will be notified by fax..." Findings: A review of Patient 10's Home Health Updated Plan of Care Report, indicated a Start of Care (SOC) of 6/8/22, and certification dates of 6/8/22-7/7/22, with diagnoses that included nursing care after open heart surgery. Further review of Patient 10's Home Health Updated Plan of Care Report included physician orders for Skilled Nursing (SN) for 1 visit for the first week, 2 visits per week for the next 2 weeks, and 1 visit per week for the next 3 weeks (1wk1, 2wk2, 1wk3). A review of the SN visit notes dated 6/15/22, indicated, "... DUE TO ADJUSTMENT IN PATIENTS NURSE VISIT SCHEDULE EARLIER THIS WEEK, PATIENT IS STATING SHE DOES NOT NEED ANOTHER NURSE VISIT THIS WEEK. NURSE OFFERED SATURDAY. PATIENT REFUSED. PATIENT HAS DOCTOR'S APPOINTMENT ON FRIDAY. SCHEDULER WILL BE NOTIFIED..." In an interview with the Director of Home Health (DHH) on 8/25/22 at 11:35 a.m., the DHH confirmed there was no physician notification of the SN missed visit for the week and stated the physician should have been notified of the missed visit. Review of the agency's policy titled, "Missed Visit or Shift," revised 2/16/22, indicated, "... If physician or allowed practitioner ordered frequency cannot be met, A Missed Visit Notification coordination note will be completed in the Patient Medical Record and the physician and if indicated, allowed practitioner will be notified by fax..." Review of Patient 10's Physician Order, dated 6/10/22, indicated an order for HHA (Home Health Aide) effective 6/19/22, twice every week for two weeks. Review of the HHA visit notes indicated only one HHA visit for the week of 6/19/22 - 6/25/22. In an interview with the DHH on 8/23/22 at 10:12 a.m., the DHH confirmed there was only one HHA visit for the week of 6/19/22 - 6/25/22 and there was one missed visit for that week. The DHH also confirmed and verified there was no documentation in Resident 10's clinical record to explain why the HHA visit was missed. Review of the agency's policy titled, "Missed Visit or Shift," revised 2/16/22, indicated, "... The clinician, Clinical Manager, and Supervisor will be notified by the Scheduler when a visit or shift is missed or refused... If physician or allowed practitioner ordered frequency cannot be met, A Missed Visit Notification coordination note will be completed in the Patient Medical Record and the physician and if indicated, allowed practitioner will be notified by fax..." Review of Patient 10's "Aide Care Plan Report," effective date of current aide care plan 6/16/22, indicated the following Care Plan Category/ Service to be performed by the HHA: "...VITAL SIGNS... VITAL SIGNS PARAMETERS... NOTIFY CASE MANAGER OR SUPERVISOR IF VITAL SIGN READING IS OUTSIDE OF PATIENT SPECIFIC PARAMETERS... REVIEW PLAN OF CARE... ADL [Activities of Daily Living] SERVICES... INTAKE/OUTPUT... DATE OF LAST BM... OTHER SERVICES..." Review of Patient 10's Physician Order dated 6/10/22 indicated an order for HHA effective 6/19/22 twice every week for two weeks, but did not include HHA services found in the Aide Care Plan Report. Review of Patient 10's Home Health Updated Plan of Care Report, SOC date 6/8/22, did not indicate the HHA services from the Aide Care Plan Report. In an interview with the DHH on 8/25/22 at 11:35 a.m., the DHH stated the actual HHA frequency order should have the verbiage order from the Aide Care Plan Report, then it would have gone to the physician for signature. The Director confirmed the Orders for HHA services, as indicated in the Aide Care Plan Report, were not signed by the physician. Review of the agency's policy titled, "Plan of Care and Allowed Practitioner Orders," revised 4/15/22, indicated, "... All care and services provided are according to current physician or allowed practitioner orders... Electronic signatures by physicians and allowed practitioners on POCs or verbal orders are acceptable if entries are appropriately authenticated, timed and dated..." Findings: Review of Patient 4's clinical record indicated she had a start of care of 6/20/22 and diagnoses included peritoneal abcess (inflammed tissue inside the abdomen). Review of Patient 4's Resumption of Care orders dated 7/29/22 contained an order for PT effective 7/31/22 for 1 time a week for 1 week. Review of Patient 4's clinical record indicated no PT visit was made the week of 7/31/22 as ordered. During an interview with Registered Nurse Supervisor (RNS) 1 on 7/31/22 at 1:40 p.m., she confirmed there was no PT visit made the week of 7/31/22. She also confirmed there was no documentation the physician was notified of the missed visit. Review of the agency's policy, "Missed Visit or Shift," revision date 2/16/22 indicated, "If physician or allowed practitiner ordered frequency canot be me, a Missed Visit Notification coordination note will be completed in the Patient Medical Record and the physician and if indicated, allowed practitioner will be notified..."

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 individualized plan of care (POC) developed for one of 17 sampled patients (Patient 9) included vital information that the patient had a newly implanted dual channel pacemaker (a device surgically implanted into patient's chest designed to monitor heart rate and deliver a strong electrical shock to restore the heart rate back to normal any time the heart rate starts to beat faster than normal or drops below the normal). Additionally, there were no instructions regarding assessing and monitoring the surgical incision site for signs and symptoms of infection and no patient teaching regarding the pacemaker. This failure placed Patient 9 at risk for complications, including infection or pacemaker malfunctioning. Findings: A review of Patient 9's clinical record indicated a start of care (SOC) date of 5/20/22 for after care following a surgery for a pacemaker. Patient 9's other diagnoses included abnormally rapid heart rate, heart failure, and high blood pressure. A review of Patient 9's POC from 5/20/22 to 7/18/22, indicated the skilled nurse (SN) was to visit the patient to evaluate and develop a plan of care for implanted cardiac pacemaker, ventricular tachycardia (a condition in which the lower chambers of the heart called ventricles, beat very rapidly), cardiac arrest (heart stopped beating), high blood pressure, syncope (fainting), and fall prevention. The POC indicated that the SN was "to assess/evaluate any conditions that present themselves and that will impact the plan of care ...to identify changes and intervene to minimize complications." The POC indicated the SN was to provide teaching and monitoring of patient and caregiver ability to safely administer medications, instructing for fall prevention, and pain management. The POC indicated, "Will demonstrate/provide education ...needed to maintain health ...Patient/caregiver will be knowledgeable..." There was no documented evidence in the POC addressing newly implanted pacemaker and its management, whether it worked on fixed or demand rate, signs of pacemaker malfunction to report and what the patient/caregiver should be taught regarding pacemaker. The POC did not contain any instructions regarding monitoring the surgical site for signs and symptoms of infection and what the patient should be observing. A further review of the POC from 5/20/22 to 7/18/22 listed Patient 9's goals, rehabilitation potential, and discharge plans. The goals listed on the POC did not contain any information indicating that patient/caregiver will verbalize and demonstrate ability and appropriate care practices to care for the surgical site to prevent infection. The patient's goals did not include any documentation that Patient 9 and her caregivers will be able to demonstrate increased knowledge and will be able to promptly identify any issues related to the pacemaker. A review of the agency's policy titled, "Plan of Care and Physician and Allowed Practitioner Orders," revised 4/22, indicated the agency's goal was to develop an individualized Plan of Care (POC) and provide care and services consistent with POC. The policy indicated, " The POC should be based upon a current assessment of the patient's needs for care. The POC must include: Any pertinent diagnoses ...Functional limitations ...Safety measures, Goals ...measurable outcomes ...other relevant patient information." During a concurrent interview and POC review on 8/24/22, commencing at 1:30 p.m., the Director of Home Health (DHH) was unable to find any documentation addressing Patient 9's pacemaker. The DHH acknowledged that Patient 9's POC did not contain any information regarding the pacemaker, beside "altered cardiovascular status." The DHH stated if it was a new pacemaker, she would expect to see assessment for signs and symptoms of infection, patient/caregiver teaching regarding risk for infection, and importance of follow up with physician. A policy addressing the care and management of the newly implanted pacemaker was requested, but not received.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to ensure the medication profile was accurate for one of seventeen sampled patients (Patient 13), when Patient 13's medication profile did not reflect medications he was taking. This failure had the potential for Patient 13 to experience adverse effects from medication interactions. Findings: A review of Patient 13's Home Health Certification and Plan of Care (POC), for certification period 8/4/22 to 10/2/22, indicated Patient 13 had a Start of Care (SOC) with the Home Health Agency on 8/4/22 with multiple diagnoses including chronic kidney disease (loss of kidney function), anemia (body does not have enough red blood cells), and atrial fibrillation (irregular, rapid heart rate). A review of Patient 13's "Client Medication Profile," provided on 8/23/22 by the home health agency, listed multiple medications entered on 8/16/22 into the medication profile, including: levothyroxine (a thyroid hormone), 25 mcg (micrograms), 1 tablet daily Calcium 600 + D(3) 600 mg (milligrams)- 10 mcg (400 unit), 1 tablet daily. During an interview on 8/24/22 at 10:00 a.m with Registered Nurse (RN) 1, RN 1 stated that patient's medications are reviewed every visit and the medication profile is updated if there are any changes in medications or any new medications. During a concurrent observation and interview that occurred during Patient 13's home visit on 8/24/22 at 12:10 p.m. with the Physical Therapist (PT), observed Patient 13's medications including: levothyroxine, 25 mcg, 1.5 tablets daily, order date on medication container was 7/11/22 calcium 500 + D 500 mg-10 mcg (400 unit) Chewable (vitamin supplement), 1 tablet daily vitamin B 12, 3000 mcg (vitamin supplement), 2 tablets daily PreserVison Areds-2, 250 mg-90 mg-1 mg capsule (supplement), 1 tablet daily. The PT acknowledged that Patient 13's "Client Medication Profile," did not accurately reflect these medications Patient 13 was taking. The PT stated she asks at each visit if there are any medication changes, but does not reconcile the medications each visit. During an interview on 8/24/22 at 2:15 with the RN Supervisor (RNS) 2, the RNS 2 stated the PT is expected to ask patients each visit if there had been any medication changes. The RNS 2 stated the nurse should have reconciled Patient 13's medicatons every visit, not just ask for medication changes. The RNS 2 acknowledged that the medication profile should have been corrected to reflect the medications Patient 13 was taking. During an interview on 8/25/22 at 9:05 a.m. with the Director of Home Health (DHH), reviewed Patient 13's "Client Medication Profile" did not match the medications that Patient 13 was taking. The DHH stated that the nurse was to verify upon the initial visit and subsequent visits, the medication that Patient 13 was taking and to update the medication profile. The DHH stated that if the medication profile was not correct, the patient may not have taken the medications properly or may have possible adverse drug interactions. A review of the home health agency's policy titled "Medication Profile," revised 2/15/22, indicated "Purpose: To review and appropriately document prescribed and over-the-counter medications currently used by the patient...Upon admission to the Agency, the admitting clinician will initiate a medication profile to document the current medication regime. The assessment review will identify current medications taken in order to identify any potential adverse effects and drug reactions...The medication profile will be updated at resumption of care, recertification, with any medication changes, and at discharge...During subsequent home visits, the medication profile will be used a a care planning and teaching guide to ensure that the patient, family and/or caregiver...other clinicians understand the medication...Using the medication profile to evaluate the use of the drugs in the home setting...Using the medication profile as a communication tool for other clinicans involved in the care..." A review of the home health agency's policy titled "Medication Management," revised 3/14/22, indicated "...The qualifying clinician assesses all the current medications patient is taking as part of the comprehensive assessment at start of care, resumption of care, recertification of services, and anytime a change or update is made to the medication profile...Medication changes and/or updates during an episode of care are recorded on the patient's medication profile through a physician's or allowed practitioner's order..."