Every finding on record at Professional Healthcare at Home, LLC

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA0062394 Representing the Department: Health Facilities Evaluator Nurse: 31403 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA0062394.

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 home health agency did not provide services as ordered for one sampled patient (Patient 1). There was no initial assessment visit made by a registered nurse. This failure resulted in unnecessary stress for Patient 1 and her family. Record review on 4/6/2022 of the policy and procedure titled, “Admission and Non-Admission” dated 3/2021, showed the agency's admission criteria included a “Reasonable expectation that the patient’s overall medical, nursing, rehabilitative, and social needs can be adequately met in their place of residence, including a plan to meet any medical emergency that may arise.” Record review at 1:40 p.m. of the document, “Hospitalist Discharge Summary Addendum” dated 1/28/2022, showed Patient 1 had cancer and had been receiving chemotherapy. Patient 1's medications included antibiotics and pain medications. Patient 1 was described as “tearful” regarding her cancer. Review of the document, “Case Management Progress Note & Discharge Plan” dated 1/28/2022, showed the hospital had contacted the agency’s representative (Home Health Consultant or HHC) at 12:51 p.m. who “Confirmed acceptance of patient and that they will start care on 1/29/22.” The case manager contacted the HHC again at 3:51 p.m. who confirmed he had in his possession the discharge summary, discharge summary addendum and the home health care orders. The agency confirmed the start of care was 1/29/2022 following Patient 1’s discharge from the hospital on 1/28/2022. Record review of the document, “Referral to Home Health – Adult Program,” dated 1/26/2022, showed, “Services Request: Registered Nurse” for Medication Management (Wound Vac/Colostomy) wound, ostomy (surgical opening in the stomach for waste to exit the body) and respiratory care. A wound vac is a device used to assist in wound healing and colostomy is a surgical operation in which a piece of the colon is connected to an opening in the abdomen in order to bypass a damaged section of the colon. Wound care to be provided every Monday, Wednesday and Friday and colostomy pouch changed twice per week. In an interview on 3/30/2022 at 2:26 p.m., Patient 1’s family member (Family Member 1) stated, “The initial visit was really critical because she had an open wound with a wound vac.” Family 1 stated an agency nurse was scheduled to make an initial visit on 1/29/2022 but “No one showed up.” When Family 1 called the agency, he was told a nurse was not available until Tuesday (4 days later). Family Member 1 further stated his wife had been through “So much” and not having a nurse make a visit was “Very stressful.” Family 1 stated no one from the agency offered to find him another agency. In an interview on 4/6/2022 at 9: 53 a.m., the Director of Nursing (DON) stated, when the agency accepts a patient and subsequently cannot provide the care, they look for another agency who is available and notify the doctor. DON stated, it was the agency’s policy to “plan ahead” and just “Not show up," and it was important to take these steps because patients require nursing care. In an interview on 4/6/22 at 10:22 a.m., DON stated Patient 1 was a referral from January 2022 but she was not in the system and did not know why. In an interview on 4/6/22 at 11 a.m. the agency’s administrator (ADM) stated Patient 1 had not been admitted to the agency and went “Somewhere else.” ADM was asked if she could produce documentation which showed what had transpired between the time the agency received the referral from the hospital and Patient 1’s transfer to another agency. ADM stated there was nothing in the clinical record which showed what had happened to Patient 1. Record review on 4/6/22 at 4:46 p.m. of the email sent to this surveyor from the ADM showed a referral for Patient 1 was received by the agency on 1/26/2022 and was listed as “open” on 1/28/2022. The last column of the email showed “1/31/2022 9:00 a.m.” and “1/28/2022 3:40 pm…placed elsewhere.” The ADM stated there were two dates in the last column because the patient had gone to another agency on 1/28/2022 and notification was sent out a second time on 1/31/2022 which indicated Patient 1 would not be starting care with the agency. In an interview on 4/6/22 at 4:33 p.m. the Home Health Consultant (HHC) stated he received an email with the referral for care for Patient 1 on 1/26/2022 and reviewed the document on 1/28/2022. HHC confirmed there had been no start of care for Patient 1 and was unsure what had happened to Patient 1. In an interview on 5/3/2022 at 10 a.m., the hospital Case Management Assistant (CMA) stated, the agency agreed to start care the next day on 1/29/2022 or within 48 hours of Patient 1’s discharge from the hospital. CMA stated the agency had not notified the hospital staff to let them know they were unable to start care on 1/29/2022. CMA further stated it was unusual for an agency not to communicate this information. In an interview on 5/3/2022 at 10:10 a.m., the hospital Registered Nurse/Case Manager (RNCM) confirmed she had spoken to HHC on 1/28/2022, who reported he had received all of the necessary documentation. RNCM stated the agency had not notified her to let her know they were unable to provide services to ensure the continuation of Patient 1’s care and treatment.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to review and update their emergency preparedness plan every two years. This deficient practice had the potential for the agency to use outdated information and unprepared to manage an emergency or disaster which could place patients at risk. During a review of the Emergency Preparedness Plan which showed the plan had not been reviewed since 2/5/19. During a review of the "Home Health Emergency Preparedness and Business Continuity Plan" for 2022, indicated the following sections were not completed: Review of emergency plan annually; review and ensure Memos of Understanding are completed and on file; review exercises and emergencies to determine gaps and need for adjustment to plan; designate alternate operations site or meeting place if agency location is not accessible; obtain listing of local emergency shelters for medical needs; or identify key individuals and local agencies and list their points of contact for coordinating plans. There was no documentation that the emergency plan was completed for 2020 or 2021. During an interview with the Branch Director (BD), on 3/10/22 at 10:00 a.m., BD stated the plan was reviewed verbally but there was no documentation of the review. BD further stated some parts had been updated and those dates are reflected on the documents. Review of the agency's policy titled, “Emergency Preparedness” last revision 11/15/17, indicated the facility will establish an Incident Command Team who will at least annually establish a chairperson; complete the hazard vulnerability assessment; review, update and approve the plan; review, update. and approve the communication plan; and schedule and track participation in annual emergency preparedness training.

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 interview and record review for five of 17 (Patients 5, 6, 7, 16 and 17) sampled patients, the home health agency (HHA) failed to meet the Condition of Participation for Care Planning, Coordination, Quality of Care when the agency licensed nursing staff did not notify the doctor for changes of conditions, follow the plan of care, and coordinate care to meet patient needs. The cumulative severity and intensity of these deficiencies resulted in the failure of the facility to meet 418.60 Care Planning, Coordination, Quality of Care. Refer to deficiencies 572, 588 and 590.

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 home health agency’s licensed staff did not follow the plan of care for five of 17 sampled patients (Patients 5, 6, 7, 16 and 17). Patient 5 exhibited an unstable gait. Patient 6 started to show signs of a potential urinary tract infection. Patient 7 had pain with urination and an elevated heart rate. Staff failed to call 911 when Patient 16 appeared unsteady and vomiting and Patient 17 had an elevated blood pressure and had no medications in the home. and minimal monitoring of her weight. These failures resulted in unnecessary hospital admissions and an inability to attain established health care goals. Record review on 3/7/2022 of the policy and procedure, “Care Planning” dated 6/2021 showed, “Each patient must receive an individualized written Plan of Care (POC) including any revisions or additions. The Individualized POC must specify: Care and services to meet the patient-specific needs as identified in the comprehensive assessment including identification of the responsible disciplines and measurable outcomes the Home Health Agency (HHA) anticipates will occur as a result of implementing and coordinating the POC.” Review of the “Home Health Certification and Plan of Care” (HHCPC) showed Patient 5’s start of care was 12/2/2021 with the current certification period 12/2/2021 to 1/30/2022. The diagnoses included emphysema (lung disease). The POC goals included, “Patient will improve static and dynamic functional balance…” and “Patient will improve gait and ambulation…” “Patient/Caregiver verbalizes/demonstrates ability to manage the risk of hospitalization or ED (Emergency Department) visits as evidenced by no hospitalization or ED visits during care.” Review of the “Visit Note Report” (VNR) dated 12/14/2021, showed Licensed Vocational Nurse 1 (LVN 1) documented Patient 5 was, “Noted with unsteady balance and unsafe sitting down.” Review of the VNR dated 12/17/2021 showed Patient 5’s caregiver had reported to the physical therapist that Patient 5 had, “Fallen 20 minutes prior to” agency staff’s arrival. Review of the VNR dated 12/17/2021, showed Patient 5’s caregiver reported to LVN 1 that he (caregiver) was “Feeling overwhelmed with patient’s care” and “…Patient balance is unsteady time to time which makes it difficult to give her a bath because he’s afraid patient will fall.” There was no documentation in the clinical record LVN 1 had notified the doctor and supervising registered nurse (RN) or had coordinated with the Physical Therapist regarding Patient 5’s unsteadiness on 12/14/2021. There was no documentation which showed the social worker had been contacted regarding Patient 5's caregiver's stress level. In an interview on 3/8/2022 at 2:10 p.m., the Clinical Manager/Director of Patient Care Services (CMDPCS) confirmed there was no documentation showing communication with the social worker and stated she would have expected LVN 1 to call the doctor and coordinate with the supervising RN and notify physical therapy. In a second interview and concurrent record review, on 3/9/2022 at 2:33 p.m., CMDPCS stated staff should have notified the social worker regarding Patient 5’s caregiver's stress and staff should have scheduled another visit sooner than the next visit on 12/21/2022. In an interview on 3/9/2022 at 11:45 a.m., LVN 1 confirmed there was no documentation in the clinical record indicating LVN 1 had notified the doctor or supervising RN regarding Patient 5’s unsteadiness that was noted on 12/14/2021 and did not coordinate with the physical therapist or social worker. Record review on 3/7/2022 of the HHCPC showed Patient 6’s start of care was 10/19/2021 with the current certification period 12/18/2021 to 2/15/2022. The diagnoses included kidney disease. Patient 6 had a catheter (tube inserted into the bladder to drain urine). The Goals/Rehabilitation Potential/Discharge Plans included, “Genitourinary (bladder) exacerbations are identified promptly and interventions initiated to minimize risks.” Review of the VNR dated 1/27/2022 showed, Patient 6’s temperature was 98 and the catheter tube and drainage were “WNL” (within normal limits meaning clear, yellow urine). Further view of the VNRs showed the following: 2/10/2022: temperature 98.9 (normal temperature is about 98.6 degrees Fahrenheit) and catheter bag showed “Sediment in urine.” 2/14/2022: temperature 99.4 with sediment in the urine. There was no documentation in the clinical record which showed staff had intervened to address the sediment in the urine and change in temperature . In an interview on 3/8/2022 at 2:10 p.m., CMDPCS confirmed there was no documentation which showed the doctor had been notified. CMDPCS further stated staff should have notified the doctor and considered the possibility of a urinary tract infection (UTI). In an interview on 3/9/2022 at 11:25 a.m., RN 1 confirmed she did not call the doctor but “Should have.” RN 1 stated this could have been the development of a UTI. Review of the HHCPC showed Patient 7’s start of care was 8/23/2021 with the current certification period 10/22/2021 to 12/20/2021. The diagnoses included UTI and goals included, “Genitourinary exacerbations are identified promptly and interventions initiated to minimize risks.” Review of the VNR dated 11/17/2021 showed Patient 7 had an elevated heart rate of 109 (normal range 60-100). Patient 7 reported to the Licensed Vocational Nurse 2 (LVN 2) she had, “Pain on urination at night.” Review of the VNR dated 12/2/2021 showed Patient 7’s heart rate was 102 and she continued to have burning with urination. There was no documentation in the clinical record which showed the nurse had intervened to address the pain and burning. In an interview on 3/8/2022 at 2:10 p.m., CMDPCS confirmed there was no documentation which showed the doctor had been notified. CMDPCS stated a sign of pain was an elevated heart rate and staff should have been considering the possibility of a UTI. CMDPCS further stated Patient 7 was transferred to another agency and her last date of service was 12/2/2021. In an interview on 3/9/2022 at 11:20 a.m., LVN 2 stated she was not sure if she had notified the doctor or not and would be concerned that Patient 7 was developing a UTI. Review of the HHCPC showed Patient 16’s start of care was 1/13/2022 with the current certification period 1/13/2022 to 3/13/2022. The diagnoses included a history of a stroke. The goals included, “Gastrointestinal exacerbations are identified promptly and interventions are initiated to minimize risks.” Review of the VNR dated 1/14/2022 showed RN 1 documented that Patient 16 stated he had not slept well the night before and had been sweating. Patient 16's temperature was 100.2 and heart rate was 105. During the visit, Patient 16 “started vomiting with brownish output…” RN 1 offered water to Patient 16 and advised the caregiver to “Keep offering fluids” and, if symptoms worsen or do not improve, “Send to ER (emergency room).” There was no documentation in the clinical record that the nurse took action to address the vomiting and increased temperature. In a concurrent record review and interview on 3/9/2022 at 10:57 a.m., CMDPCS confirmed there was no follow-up with the doctor regarding Patient 16's change of condition. Review of the “Medical Record – Progress Notes” showed Patient 16 was admitted to the hospital on 1/20/2022 with “Vomiting, diarrhea, and abdominal pain." Review of the "Discharge Summaries (Emergency Department or ED and Hospital Discharges)" dated 1/23/2022 showed Patient 16 was admitted with gastroenteritis (intestinal infection) and gastroparesis (delayed stomach emptying) and tested positive for COVID 19. Patient 16 remained in the hospital for three days and received intravenous (IV) hydration and replacement of his electrolytes (essential minerals). Review of the HHCPOC on 3/9/2022, showed Patient 17’s start of care was 8/2/2021 with the current certification period 8/2/2021 to 9/30/2021. The diagnoses included a heart attack. The physician orders included, “Skilled nurse to observe/assess cardiovascular system, identify changes, and intervene to minimize complications. Skilled Nurse to teach related to altered cardiovascular status including disease process, nutrition, medications, activities, personal/environmental factors, and to report weight gain of 2-3 lbs (pounds/ day or 5 LBS/wk.” Review of the VNR showed the following: 8/27/2021 – plus 3 edema in lower left and lower right extremity (indicator of fluid retention by pressing gently on the skin. Level 1 (lowest) Level 4 (highest). Blood Pressure (BP) 115/76 (120/70 normal range). There was no documented weight (indicator of fluid load and potential pressure on the heart). Breath sounds were diminished (indicating potential air or fluid in and around the lungs). 9/1/2021 – BP 154/86. Plus 3 edema with diminished breath sounds. No documented weight. Registered Nurse 2 (RN 2) documented Patient 17 reported she will “Hold off previously ordered medication until she sees her PCP.” Medications that were not taken included, Bumex (water pill) medication used to eliminate excess fluid from the body and ease pressure on the heart) and Metoproplol (treats high BP). 9/3/2021 – BP 139/86. Plus 3 edema with diminished breath sounds. No documented weight. RN 2 documented, “No more med (medication) refill only has ASA (aspirin) and Montelucast (anti-inflammatory) available. MD was notified. 9/7/2021 - RN 1 documented she discussed the importance of checking weight daily and to report significant weight gain to her primary care physician. 9/10/2021 – LVN 2 documented Patient 17’s BP was 184/102 (elevated and outside established parameters). LVN 2 notified the doctor who reported Patient 17’s medications had been sent to the pharmacy on 9/2/2021 (8 days ago). Review of the “Vital Signs Report” showed Patient 17’s weight was 240 pounds on 9/27/2021. Review of the document “Client Coordination Note Report dated 9/30/2021 showed Patient 17 weighed 235 pounds. There were no other documented weights in the clinical record. Note: RN 2 was not available to be interviewed. In an interview on 3/9/2022 at 4:09 p.m., RN 1 confirmed there was no documented weight for Patient 17 during her visit on 9/7/2021 and she had, “Done nothing about the medication since the patient had an appointment on 9/17 already” (10 days later). Patient 17 went to the hospital's ED on 9/16/2021. Review of the document, “ED Provider Note” dated 9/16/2021, showed Patient 17 arrived at the ED with, “Bilateral lower extremity swelling…”, weeping (oozing) bilateral leg wounds, chills, fever and shortness of breath. Her temperature was 101.6 and BP 176/56.

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’s licensed staff did not update the plan of care for two of 17 sampled patients (Patients 5 and 7). Patient 5 was experiencing falls which had created more stress for her caregiver and Patient 7 had pain with urination and an elevated heart rate. This failure resulted in unmet health care goals when the care plans were not revised according to the patient's condition to prevent further decline in physical health. Review on 12/7/2022 of the policy and procedure, “Care Planning” dated 6/2021, showed “Plans of Care will be reviewed and revised as necessary to meet the changing needs of the patient in the most effective manner to achieve the desired outcomes.” Review of the “Home Health Certification and Plan of Care” (HHCPC) showed Patient 5’s start of care was 12/2/2021 with the current certification period 12/2/2021 to 1/30/2022. The diagnoses included emphysema (lung disease). The orders for discipline and treatments included, “Skilled Nurse to observe for fall risk, identify changes, and intervene to minimize complications.” Review of the “Visit Note Report” (VNR) dated 12/14/2021, showed Licensed Vocational Nurse 1 (LVN 1) had documented Patient 5 was “Noted with unsteady balance and unsafe sitting down.” Review of the VNR dated 12/17/2021 showed Patient 5’s caregiver reported to the physical therapist Patient 5 had “Fallen 20 minutes prior to” agency staff’s arrival. Review of the VNR dated 12/17/2021 showed Patient 5’s caregiver had reported he was feeling “overwhelmed" with Patient 5’s care due to her balance issues and risk for fall. There was no documentation in the clinical record LVN 1 had notified the doctor, physical therapist, social worker or supervising RN regarding Patient 5’s unsteadiness on 12/14/2021 and the caregiver’s stress. In an interview on 3/8/2022 at 2:10 p.m., the Clinical Manager/Director of Patient Care Services (CMDPCS) confirmed there had been no update to the plan of care related to Patient 5's unsteadiness and high risk for falls. CMDPCS stated she would have expected LVN 1 to call the doctor and coordinate with the supervising RN to further minimize the risk of falling and revise the care plan. In an interview on 3/9/2022 at 11:45 a.m., LVN 1 confirmed there was no update to the plan of care which reflected Patient 5's increasingly unsteady gait and the primary caregiver's stress level. In an interview on 3/9/2022 at 2:33 p.m., CMDPCS stated Patient 5’s plan of care had not been updated to reflect the unsteadiness and caregiver stress. CMDPC further stated Patient 5 “Could have used a social worker” on both 12/14/2021 and 12/17/2021. Review of the HHCPC showed Patient 7’s start of care was 8/23/2021 with the current certification period 10/22/2021 to 12/20/2021. the diagnoses included urinary tract infection (UTI). The orders of Discipline and treatments included, “Skilled nurse to observe/assess for pain, effectiveness of pain management regimen, identify changes, intervene to minimize complications, and provide skilled teaching related to pain management.” Review of the VNR dated 11/17/2021 showed Patient 7 had an elevated heart rate which was 109 (normal range 60-100). Patient 7 reported to the Licensed Vocational Nurse 2 (LVN 2) she had “Pain on urination at night.” Review of the VNR dated 12/2/2021 showed Patient 7’s heart rate was 102 and she continued to experience burning with urination. There was no documentation in the clinical record that the doctor had been notified or an attempt made to obtain a urine sample for testing which required a care plan update for Patient 7. In an interview on 3/8/2022 at 2:10 p.m., CMDPCS confirmed there was no update to the plan of care which reflected the burning with urination and elevated heart rate. CMDPCS stated staff should have been considering the possibility of a UTI and the elevated heart rate could have been a sign of pain or infection. CMDPCS further stated Patient 7 transferred to another agency and her last date of service was 12/2/2021. Review of the other receiving agency's “Home Health Certification and Plan of Care” showed the agency admitted Patient 7. Patient 7's start of care was 12/17/2021 and was admitted with a UTI and started on antibiotics. In an interview on 3/9/2022 at 11:20 a.m., LVN 2 stated she was not sure if she had notified the doctor or not. In an interview on 9/2022 at 2:33 p.m., CMDPCS confirmed was no update to the plan of care to reflect the pain. Staff should have been getting an order from the doctor for a UA (urinalysis, a test to detect urinary bladder infection).

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency did not notify the doctor for changes in condition for five of 17 sampled patients (Patients 5, 6, 7, 16, and 17). Patient 5 had been experiencing falls. Patient 6 had an elevated temperature and sediment in his urine and Patient 7 had pain with urination and an elevated heart rate. Patient 16 had a temperature and vomited brownish liquids while staff continued to offer liquids and did not call the doctor or 911. Patient 17 had an elevated blood pressure without the necessary medications in her home. These failures resulted in unsafe care, pain and emergency department/hospital admissions, including the inability to attain established healthcare goals. Record review on 3/7/2022 of the agency’s policy and procedure, “Care Planning” dated 6/2021, showed “The primary care physician or allowed practitioner, patient, patient representative (if any), and caregiver will be notified as appropriate if the clinicians identify changes in the patient’s condition that indicate a need to change the Plan of Care/Plan of Treatment. The clinician or clinical manager will notify the physician or allowed practitioner rather than having the patient or family make the contact.” Review of the “Home Health Certification and Plan of Care” (HHCPC) showed Patient 5’s start of care was 12/2/2021 with the current certification period 12/2/2021 to 1/30/2022. The diagnoses included emphysema (lung disease). Review of the “Visit Note Report” (VNR) dated 12/14/2021, showed Licensed Vocational Nurse 1 (LVN 1) documented Patient 5 was “Noted with unsteady balance and unsafe sitting down.” Review of the VNR dated 12/17/2021 showed Patient 5’s caregiver reported to the physical therapist Patient 5 had “Fallen 20 minutes prior to” agency staff’s arrival. There was no documentation in the clinical record LVN 1 had notified the doctor regarding Patient 5’s unsteadiness on 12/14/2021. In an interview on 3/8/2022 at 2:10 p.m., the Clinical Manager/Director of Patient Care Services (CMDPCS) confirmed no documentation and stated she would have expected LVN 1 to call the doctor and coordinate with the supervising registered nurse (RN). In an interview on 3/9/2022 at 11:45 a.m., LVN 1 confirmed there was no documentation in the clinical record she had notified the doctor regarding Patient 5’s unsteadiness. Record review on 3/7/2022 of the HHCPC showed Patient 6’s start of care was 10/19/2021 with the current certification period 12/18/2021 to 2/15/2022. The diagnoses included kidney disease. Patient 6 had a catheter (tube inserted into the bladder to drain urine). Further view of the VNRs showed the following: 2/10/2022: temperature 98.9 and catheter bag showed “Sediment in urine.” 2/14/2022: temperature 99.4 with sediment in the urine. There was no documentation in the clinical record which showed the doctor had been notified regarding the sediment in the urine with the change in temperature. In an interview on 3/8/2022 at 2:10 p.m., CMDPCS confirmed there was no documentation which showed the doctor was notified. CMDPCS stated staff should have notified the doctor and considered the possibility of a urinary tract infection (UTI). In an interview on 3/9/2022 at 11:25 a.m., Registered Nurse 1 (RN 1) confirmed she did not call the doctor and stated she should have. RN 1 stated this could have been the development of a UTI. Review of the HHCPC showed Patient 7’s start of care was 8/23/2021 with the current certification period 10/22/2021 to 12/20/2021. The diagnoses included UTI. The orders of discipline and treatments included, “Skilled nurse to observe/assess for pain, effectiveness of pain management regimen, identify changes, intervene to minimize complications, and provide skilled teaching related to pain management. Significant changes in status will be reported to physician.” Review of the VNR dated 11/17/2021 showed Patient 7 had an elevated heart rate which was 109 (normal range 60-100). Patient 7 reported to the Licensed Vocational Nurse 2 (LVN 2) she had “Pain on urination at night.” Further review showed Patient 7’s daughter had called the doctor and was “Still waiting for a call back.” Review of the VNR dated 12/2/2021 showed Patient 7’s heart rate was 102 and she continued to have burning with urination. There was no documentation in the clinical record that the doctor was notified. In an interview on 3/8/2022 at 2:10 p.m., CMDPCS confirmed the doctor was not notified and stated an elevated heart rate could be a sign of pain and staff should have considered the possibility of a UTI. CMDPCS stated Patient 7 transferred to another agency and her last date of service was 12/2/2021. In an interview on 3/9/2022 at 11:20 a.m., LVN 2 stated she was not sure if she had notified the doctor about Patient 7 (possible UTI). Review of the HHCPC showed Patient 16’s start of care was 1/13/2022 with the current certification period 1/13/2022 to 3/13/2022. The diagnoses included a history of a stroke. The orders included, “Skilled nurse to assess/evaluate co-morbid conditions including CVA (cerebrovascular accident or stroke), and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications. Significant changes in status will be reported to the physician.” Review of the VNR dated 1/14/2022 showed RN 1 documented that Patient 16 stated he had not slept well the night before and had been sweating. Patient 16's temperature was 100.2 (normal 98.6) and heart rate 105 (normal 60-100). During the visit, Patient 16 “started vomiting with brownish output…” RN 1 offered water to Patient 16 and advised the caregiver to “Keep offering fluids” and, if symptoms worsen or do not improve, “Send to ER.” There was no documentation in the clinical record which showed the doctor had been called or considered calling 911 for immediate medical care. In a concurrent record review and interview on 3/9/2022 at 10:57 a.m., CMDPCS confirmed there had been no follow-up with the doctor. Review of the “Medical Record – Progress Notes” showed Patient 16 was admitted to the hospital on 1/20/2022 with “Vomiting, diarrhea, and abdominal pain." Review of the document, "Discharge Summaries," (Emergency Room and Hospital Discharges) dated 1/23/2022 showed Patient 16 had been admitted with gastroenteritis (intestinal infection) and gastroparesis (delayed stomach emptying) and tested positive for COVID 19. Patient 16 remained in the hospital for three days and received intravenous (into the vein) hydration and replacement of his electrolytes (essential minerals). Review of the HHCPOC on 3/9/2022, showed Patient 17’s start of care was 8/2/2021 with the current certification period 8/2/2021 to 9/30/2021. The diagnoses included a heart attack. The orders included, “Skilled nurse to observe/assess cardiovascular system, identify changes, and intervene to minimize complications. Skilled Nurse to teach related to altered cardiovascular status including disease process, nutrition, medications, activities, personal/environmental factors, and to report weight gain of 2-3 LBS/day or 5LBS/wk.” Review of the VNR showed the following: 8/27/2021 – plus 3 edema in lower left and lower right extremity (indicator of fluid retention by pressing gently on the skin. Level 1 (lowest) Level 4 (highest). Blood Pressure (BP) was 115/76 (120/70 normal range). There was no documented weight (indicator of fluid overload and potential pressure on the heart). Breath sounds were diminished (indicating potential air or fluid in and around the lungs). 9/1/2021 – BP 154/86. Plus 3 edema with diminished breath sounds. No documented weight. RN 2 documented Patient 17 reported she will, “Hold off previously ordered medication until she sees her PCP (primary care provider).” Medications that were not taken included, Bumex (water pill to remove excess fluid and ease pressure on the heart) and Metoproplol (BP medication). 9/3/2021 – BP 139/86. Plus 3 edema with diminished breath sounds. No documented weight. RN 2 documented, “No more med (medication) refill only has ASA (aspirin) and Montelucast (anti-inflammatory) available. MD was notified. 9/7/2021 - RN 1 documented she discussed importance of checking weight daily and to report significant weight gain to her primary care physician. 9/10/2021 – LVN 2 documented Patient 17’s BP was 184/102 (elevated and outside established parameters). LVN 2 notified the doctor who reported Patient 17’s medications were sent to the pharmacy on 9/2/2021 (8 days ago). Review of the document “Vital Signs Report” showed Patient 17’s weight was 240 pounds on 9/27/2021. Review of the document “Client Coordination Note Report dated 9/30/2021 showed Patient 17 weighed 235 pounds. There were no other documented weights in the clinical record. RN 2 was not available to be interviewed. In an interview on 3/9/2022 at 4:09 p.m., RN 1 confirmed there was no documented weight for Patient 17 during her visit on 9/7/2021 and she had “Done nothing about the medication since the patient had an appointment on 9/17 already” (10 days later). Patient 17 went to the hospital Emergency Department (ED) on 9/16/2021. Review of the document, “ED Provider Note” dated 9/16/2021, showed Patient 17 arrived at the ED with “Bilateral lower extremity swelling…”, weeping (oozing) bilateral leg wounds, chills, fever and shortness of breath. Her temperature was 101.6 with a BP 176/56.