Every finding on record at Prohealth Home Care, Inc.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on interview and record review, for one of 10 sampled patients (Patient 4), the agency failed to ensure the comprehensive assessment accurately reflected Patient 4’s continuing need for home health benefit. This failure had the potential to result in Patient 4 not meeting the criteria for home health eligibility and the “Plan of Care” not being appropriate for their needs. During a review of Patient 4’s “Non-Oasis RN Recert (NORR)” dated 4/2/25, the “NORR” indicated Patient 4’s start of care date was 2/1/25 and was re-certified to receive home health services for the period 4/2/25-5/31/25. The “NORR” indicated Patient 4 was alert, oriented x 3, had no activity restrictions, denied pain, vital signs were stable, lungs were clear, no edema, independent with most activities of daily living like toileting, ambulation, meal prep, dressing, transfers and eating, and no signs of infection. During a review of the “Skilled Nursing Visit Note (s) (SNVN)”, the “SNVN” indicated the following: -On 4/4/25, “Found [Patient 4] outside working on a car. Alert and verbal. Able to answer questions asked appropriately. [Patient 4] denied pain and discomfort, No SOB (shortness of breath) or respiratory distress noted…[Patient 4 voiced] no concerns at this time. [Continue] to be independent with ADL’s and able to [do] her hobby such as working or doing auto mechanic which she enjoys doing…” -On 4/8/25, “Found patient outside doing yard work…[Patient] voiced no concerns…” -On 4/17/25, “Patient reported that she is out of town, she is staying at her daughter’s place in Long Beach…” -On 4/23/25, “Nephrostomy care provided by her sister yesterday…” During a concurrent interview and record review on 5/12/25 at 1:57 p.m. with Director of Patient Care Services (DPCS), DPCS stated the clinician should have called the agency office to clarify if Patient 4 needed to continue homebound status, if a patient is out of town, it means the patient is not homebound and needs to be discharged from home health services. Patient 4's chart showed a case conference dated 4/2/25 "pending" (not completed) for the certification period starting 4/2/25. During a review of the agency's policy and procedure (P&P) titled "Admission Criteria and Process" last revised November 2020, the P&P indicated "A person is considered homebound if he/she has a condition that restricts his/her ability to leave his/her place of residence except with the aid of supportive devices, the use of special transportation, the assistance of another person, or if he/she has a condition which is such that leaving his/her home is medically contraindicated." During another review of the agency's P&P titled "Reassessments/Recertification" last revised November 2020, the P&P indicated, after the reassessment is conducted, a case conference will be held and documented in the patient's clinical record, an updated plan of care will be prepared and sent to the physician for review and signature in a timely manner.

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 Agency’s licensed nursing staff did not provide education to patient and his or her caregiver(s) of disease process for one of 10 sampled patients (Patient 8) when Patient 8 had symptoms of urinary tract infection. This resulted in unnecessary hospital admissions and delay in making progress towards established healthcare goals. Record review of the document “Monitoring Patient’s Response/Reporting to Physician” dated 11/2020, showed “Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit…During each home visit, the clinician will monitor, document, and report the patient’s response to care against established goals, including…a. Care interventions and treatments…C. Teaching… Record review of Patient 8's document “Plan of Care” showed Patient 8’s start of care was 4/25/25 with certification period 4/25/25 – 6/23/25. Diagnoses included chronic respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen levels and/or high carbon dioxide levels in the blood over a long period) and benign prostatic hyperplasia (BPH, enlargement of prostate gland that can cause urination difficulty). Further review of the “Plan of Care” showed Patient 8 was taking one medication for BPH. Record review of the document “Skilled Nursing Visit Notes” (SNVN) dated 4/28/25 showed Patient 8 reported 5/10 pain level on the lower abdomen when urinating. SNVN also showed Patient 8 had urinary dribbling (involuntary leakage of urine shortly after urinating), pain and hesitancy (difficulty to start or maintain a urine stream). Further review of the SNVN showed no documented full assessment of the urinary system and no education on the disease process provided to Patient 8 and Patient 8's caregiver. Record review of Patient 8's document “Transfer” dated 4/30/25 showed Patient 8 was taken to the Emergency Department on 4/29/25 due to bladder discomfort and nasal congestion. Further review of the document showed Patient 8 was prescribed a medication for urinary tract infection (UTI, infection of any part of the urinary system). The document also showed Patient 8 was admitted to the hospital on 4/30/25 due to worsening of respiratory symptoms. During a concurrent interview and record review of Patient 8’s clinical records on 5/12/24 at 2:14 p.m. with the DPCS, the DPCS confirmed the clinician did not perform assessment on Patient 8’s urinary system during 4/28/25 visit. The DPCS stated the clinician should have conducted a full assessment of Patient 8’s urinary system when Patient 8 complained of urinary dribbling, pain and hesitancy. The DPCS stated the clinician should have assessed Patient 8’s urinary system such as presence of blood, odor and the color of urine. DPCS stated the clinician should have educated Patient 8 and/or the caregiver on the disease process including the symptoms and not just leaving a message to the physician.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency did not maintain complete clinical records for 3 of 10 sampled patients (Patients 2, 6, and 7). Patient records were missing visit notes, care coordination notes, and case conference notes. This resulted in an inability to assess patient progress towards established health care goals. Record review of the document “Entries Into The Clinical Record” dated November 2020, showed “Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical record will be made on the day care is provided to the patient.” Record review of the document “Plan of Care” showed Patient 2’s Start of Care was 1/19/2025 with the current certification period 3/20/2025 – 5/18/2025. Diagnoses included Lupus (autoimmune disease). Review of the document “Patient Chart” showed there were “Pending” notes for the Inter-Office Communication Note (not dated) and the Case Conference on 3/18/2025. Record review of the document “Plan of Care” showed Patient 6’s Start of Care was 4/21/2025 with the current certification period 4/21/2025 – 6/19/2025. Diagnoses included heart disease. Review of the document “Patient Chart” showed there were “Pending” notes for the Care Coordination note on 4/21/2025 and for the Case Conference on 4/21/2025. During an interview on 5/12/2025 at 1:05 p.m. the Agency’s Director of Patient Care Services (DPCS) stated “Pending” means the note requires a signature or something is missing in the documentation. During an interview and concurrent record review on 5/12/2025 at 1:45 p.m. the DPCS confirmed the missing and incomplete notes for Patients 2 and 6 and stated it was important to have complete notes so other disciplines or the doctor knows what is going on with the patient. During a review of Patient 7’s “Plan of Care” dated 4/21/25, the Plan of Care indicated Patient 7 was to have skilled nursing visits twice weekly for eight weeks starting 4/21/25. During a concurrent interview and review of Patient 7’s chart on 5/12/25 at 2:11 p.m. with DPCS, Patient 7’s chart indicated, the week of 4/27/25, DPCS confirmed Patient 7 received only one visit from skilled nurse instead of two. DPCS stated, even if it was a missed visit for any reason, it should be documented as such in the chart, and the office and the patient’s physician needs to be notified.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. 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 to ensure established healthcare goals were met for 4 of 8 sampled patients (Patients 3, 6, 7 and 8). Patients 3 and 6 had no plan of care. Patients 7 and 8 had incomplete Start of Care Assessments and incomplete transfer documents. This resulted in the agency’s inability to ensure progress had been made toward identified goals and that the care provided was based on patient needs. Record review of the document “Care Planning Process” dated November 2020, showed “A written individualized plan of care will be initiated with the five (5) days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient plan of care will be developed or revised within the five (5) working days of initiation of each service or of the reassessment of the patient. All clinicians including the physician involved in the patient’s care will participate in decisions regarding the plan of care wherever possible. The care planning process will be documented on the plan of care, individualized discipline-specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries.” Record review of Patient 3’s clinical document “Medication Profile” dated 11/12/2024, showed Patient 3’s Start of Care was 9/18/2024. Further review of the profile showed Patient 3 was taking 3 medications for high blood pressure. Record review of the document “Skilled Nursing Visit Note” dated 1/23/2025, showed Patient 3’s blood pressure was 154/77 (normal range 120/80). Review of the clinical record showed no plan of care with parameters for reporting the blood pressure to the doctor. In a concurrent interview at 1:20 p.m. on 2/11/2025, with the Director/Director of Nursing (DDON), the DDON confirmed there was no plan of care in the clinical record which showed guidance for maintaining a specific blood pressure range. Record review of the document “Source Note” dated 1/28/2025, showed Patient 3 was taken to the Emergency Department with a systolic blood pressure in the 200’s. (systolic: lower number - normal range approximately 80). Patient 3 remained in the hospital for 3 days. Record review of Patent 6’s clinical document “Home Health Physician Orders” dated 1/23/2025 showed “Patient has a history of basal cell carcinoma, diabetes, neuropathy of legs.” Record review of the documents “Skilled Nursing Visit Notes” dated 1/27/2025, 1/30/2025 and 2/3/2025 showed completed visits with notes. Review of the document “Patient Information” (screen shot of nursing visits) showed a visit took place on 2/6/2025 without accompanying notes. There was no documented plan of care in the clinical record. In a concurrent interview at 1:53 p.m. on 2/11/2025, with DDON, the DDON confirmed there was no documented visit note since 2/3/2025 or plan of care in Patient 6’s clinical record. The DDON stated “We don’t know what is going on with this patient.” Record review of Patient 7’s clinical document “OASIS RN Start of Care” dated 2/3/2025, showed Registered Nurse 3 (RN 3) visited Patient 7 to initiate care on 2/3/2025. The visit notes were blank. Review of the document, “Death at Home Transfer” signed by Physical Therapist 1 (PT 1) dated 2/7/2025 was also blank. In a concurrent interview on 2/11/2025 at 1:10 p.m. the DDON stated “I don’t know what happened to this patient.” RN 3 was not available to be interviewed. Record review of Patient 8’s document “OASIS RN Start of Care” dated 2/3/2025 showed Registered Nurse 3 (RN 3) visited Patient 8 to initiate care on 2/3/2025. The nursing notes were blank. Review of the document “OASIS Transfer/Death” dated 2/8/2025 showed Patient 8 had an unscheduled transfer to a hospital. In a concurrent interview on 2/11/2025 at 1:09 p.m. with the DDON, DDON confirmed the start of care was incomplete and Patient 8 had gone to a hospital. The DDON stated “We have no idea what happened with this patient.”

The following reflects the findings of the California Department of Public Health during the investigation of one complaint. Complaint number: 109217 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the Agency. One deficiency was written as a result complaint number 109217. See Tag G436

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 home health agency’s licensed nursing staff did not provide the number of visits as ordered by the doctor for one of 10 sampled patients (Patient 3). Patient 3 was to have visits through 5/25/2024. Her last documented visit was 5/16/2024. This resulted in the potential for unmet healthcare goals. Record review of the document “Ongoing Assessments,” dated 11/2020, showed “During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits.” Review of the document “Monitoring Patient’s Response/Reporting to Physician,” dated 11/2020, showed “Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress towards goals will be measured at regular intervals.” Record review of the document “Plan of Care” showed Patient 3’s Start of Care was 4/20/2024 with the current certification period 4/20/2024 – 6/18/2024. Diagnoses included a wound. Goals included “Signs and symptoms of infection will be identified and physician notified for prompt intervention.” Doctor’s orders included licensed nursing visits 1 time per week for 6 weeks starting 4/20/2024. Record review of the documents “Skilled Nursing visit Note(s)” showed visits took place on 4/20/2024, 4/24/2024, 4/27/2024, 5/4/2024 and 5/16/2024. There were no further documented visits for Patient 3. During an interview on 8/27/2024 at 11:15 a.m., the DON confirmed the missing visits. The DON stated the licensed nurse was no longer with the agency and could not be interviewed. The DON stated it was important to make all visits as ordered in order to assess issues such as wounds.

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 record review and interview, the home health agency failed to ensure that six patients (Patients 3, 5, 6, 10, 11, and 12), out of 13 patients sampled, received nursing visits as ordered in the plan of care. This deficiency had the potential to result in unmet goals, hospitalizations, and a worsening in condition. During a review of the agency’s policy titled, Provision of Care, Treatment, and Service, dated 11/20, the policy indicated the Clinical Supervisor will assign clinical personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information; the initial visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return home, or on the start of the care date ordered by the physician; in the event that the time frame for assessment cannot be met, the patient's physician and the referral source, as well as the patient, will be notified for approval of the delay; notification and approval will be documented; if approval is not obtained for the delay, the patient will be referred to another organization for services. During a clinical record review for Patient 5, start of care date 11/26/21, certification period 1/25/22- 3/25/22, the Physician Orders indicated a verbal order was taken on 1/27/22 for skilled nursing care. During a review of Skilled Nursing Initial Evaluation/Assessment, the document indicated the initial assessment was completed on 2/3/22 and the skilled nursing frequency would be twice a week for three weeks and once a week for one week. During an interview with the Director of Patient Care Services (DPCS) on 2/8/22 at 10:40 a.m., DPCS stated the initial assessment should have been completed within 48 hours of receiving the order. During a review of the policy titled Provision of Care, Treatment, and Service, dated 11/20, the policy indicated the initial visit must be performed within 48 hours of the referral. During a clinical record review for Patient 10, start of care date 1/19/22, certification period 1/19/22- 3/19/22, the Plan of Care document indicated a skilled nursing visit twice a week for three weeks and once a week for two weeks. Initial evaluation completed on 1/19/22 and no further visits documented. During a telephone interview with Patient 10 on 2/10/22 at 10:00 a.m., Patient 10 stated she did not decline the home visits but has only had one from the nurse on 1/19/22. During an interview with the DPCS on 2/9/22 at 2:30 p.m., DPCS stated Patient 10 could have a worsening in condition requiring hospitalization if not seen. During a clinical record review for Patient 11, start of care date 12/17/21, certification period 12/17/22 – 2/14/22, the Plan of Care document indicated a need for skilled nursing visits two times a week for three weeks starting on 1/23/22 then once a week for three weeks. Review of the record indicated the only visit in the three week period was on 1/31/22. During a telephone interview with Patient 11 on 2/14/22 at 2:25 p.m., Patient 11 stated he had not had a visit in about 2 weeks and was told he needed to be recertified before visits could resume. Review of the Inter-Office Communication Note dated 2/3/22 indicated care was being provided without an order. During an interview with the DPCS on 2/9/22 at 2:30 p.m., DPCS stated Patient 11 could have a worsening in condition requiring hospitalization if not seen and possible infection in his wound. DPCS stated health care goals will not be met without visits. During a clinical record review for Patient 12, start of care date 11/21/21, certification period 1/20/22 – 3/20/22, the Plan of Care document indicated a skilled nursing visit two times a week for three weeks starting on 1/23/22 ending on 2/12/22. Review of the record indicated Patient 12 received only one visit the week of 1/31/22. During an interview with the DPCS on 2/9/22 at 2:30 p.m., DPCS stated Patient 12 could have a high potential of hospitalization and worsening in condition. DPCS stated health care goals will not be met without visits. Record review on 2/7/2022 of the document “Plan of Care” showed Patient 3’s start of care was 1/26/2022 with the current certification period 1/26/22 to 3/26/2022. Diagnoses included hypertension (high blood pressure). Orders included skilled nursing visits twice a week for 2 weeks starting 1/26/2022. Review of the document “Start of Care Version” showed a nursing visit took place on 1/26/2022. There were no further documented nursing visits for Patient 3. In an interview at 3:38 p.m. on 2/7/2022, the agency’s Director of Patient Care Services (DPCS) confirmed Patient 3 had not received any of the ordered nursing visits past 1/26/2022. Patient 3 was not available for an interview. Record review on 2/8/2022 of the document “Plan of Care” showed Patient 6’s start of care was 12/13/2021 with the current certification period 12/13/2021 to 2/10/2022. Diagnoses included chronic obstructive pulmonary disease (lung disease). Respiratory goals included a decrease in dyspnea (shortness of breath), to be free of respiratory infections and be able to demonstrate deep breathing/coughing exercises. Record review on 2/8/2022 of the document "Home Health Physician Orders" dated 12/28/2021, showed Patient 6 had been discharged from skilled nursing services but continued to receive PT (physical therapy: physical strengthening) services. Review of the document “Home Health Physician Orders” dated 1/30/2022 and showed “Skilled nurse to evaluate and develop plan of care…to assess/evaluate co-morbid conditions including O2 (oxygen) use and cardiovascular concerns as well as assess skin integrity and other conditions that present themselves during this episode.” Review of the agency’s intercommunications notes dated 1/28/2022 showed the administrator had asked nursing staff to follow up with Patient 6 “ASAP” as Patient 6 had the beginning of “Heel sores on both feet…” There was no documentation in the clinical record which showed Patient 6 received further nursing visits. In a concurrent interview on 2/8/2022 at 11:40 a.m., the Director of Patient Care Services (DPCS) confirmed physician orders had been written for additional nursing services on 1/30/2022 which were not provided for Patient 6. In an interview on 2/8/2022 at 2:11 p.m., Patient 6’s family member (Family Member 1) confirmed no nurse had visited since the order was written on 1/30/2022. She stated Patient 6 had “A lot going on” and his breathing was “Not good.” In an interview on 2/9/2022 at 11:10 a.m., Patient 6 confirmed no nurse had visited since he was discharged on 1/28/2022.

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 clinical staff conducted a current review of all medications the patient was currently using for two, Resident 4 and Resident 5, of 13 sampled patients. This failure prevents the agency from identifying any potential adverse effects and drug interactions that could place Resident 4 and Resident 5 at risk for negative outcomes. The agency’s policy titled, Care Planning Process, dated 11/20, indicated all clinicians will consider assessments in their care planning process to include clinical drug monitoring and education of all medications. It also indicated the agency would provide the patient and caregiver with a copy of written instructions outlining medication schedule and instruction, including medication name, dosage, and frequency. During a clinical record review for Patient 4, start of care date 2/3/22, certification period 2/3/22 -4/3/22, the Medication Profile indicated Patient 4 was taking Amoxicillin (antibiotic) Pot Clavulanate 500-125 1 tablet twice a day for 7 days, Allopurinol (gout medication) 100 mg (milligram) every morning, Amlodipine ( treats high blood pressure) 5 mg every morning, Tamsulosin (for urinary retention) HCl (hydrochloride) 0.4 mg every morning, Aspirin 81 mg every afternoon, Folic Acid (vitamin) 1 mg twice per day, Levothyroxine (for low thyroid levels) Sodium 125 mcg (microgram) before breakfast, Pantoprazole (stomach reflux)Sodium 40 mg daily, Ascorbic Acid (vitamin) 1000 mg daily, Cholecalciferol (vitamin D) 50 mcg daily, and Cyanocobalamin (vitamin B 12) ER (extended release) 1000 mcg daily. During a home visit on 2/8/22 at 12:00 p.m., a review of Patient 4’s medication bottles indicated Folic Acid 1 mg was ordered for once a day, the antibiotic ordered was Bactrim 500 mg twice a day for seven days, and there was a bottle of Lasix (water pill). During a review of Patient 4’s medication list, had reflected the list in his clinical record. During an interview with Patient 4 on 2/8/22 at 12:30 p.m., Patient 4 stated he takes the Folic Acid as instructed on the written list that he has. Patient 4 stated he does not recall his physician increasing the dose from 1 mg daily to twice a day. Patient 4 stated he’s been taking the Bactrim as directed and was on a different antibiotic a couple of months ago. Patient 4 stated he does not think he is taking the Lasix. During an interview with Registered Nurse (RN) 2 on 2/8/22 at 12:40 p.m., RN 2 stated he thought the antibiotic for Patient 4 was Augmentin (Amoxicillin-Pot Clavulanate) and did not realize there was a discrepancy with the Folic Acid. During a clinical record review for Patient 5, start of care date 11/26/21, certification period 1/25/22- 3/25/22, Medication Profile indicated Patient 5 was taking Carbidopa-Levodopa 25-100 mg one tablet at 8:00 a.m., 12:00 p.m., and 4:00 p.m., Carbidopa-Levodopa 25-100 mg two tablets three times a day, Cholecalciferol 25 mcg daily, Cyanocobalamin 1000 mcg daily, Folic Acid 1 mg two tablets daily, Melatonin 3 mg at bedtime, Midodrine HCL 10 mg daily as needed for systolic blood pressure less than 100, Sertraline 50 mg daily, Docusate Sodium 100 mg two capsules daily, Acetaminophen ER 650 mg two tablets every 6 hours, Baclofen 10 mg twice per day as needed, Lyrica 20 mg twice per day, Erythromycin 5% one drop right eye twice a day, and Acetaminophen 500 mg one or two tablets every 8 hours as needed for pain. During a home visit on 2/8/22 at 2:00 p.m., a review of Patient 5’s medication bottles and home list indicated Carbidopa-Levodopa (treats Parkinson's Disease, a disorder that affects movement, often including tremors) 25-100 mg two tablets four times a day at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 8:00 p.m., Carbidopa-Levodopa 25-100 mg ER two tablets at 10:00 a.m. and 9:00 p.m., Sertraline (antidepressant) 150 mg daily, Pregabalin (nerve pain medication) 25 mg twice a day, Tylenol 500 mg two tablets twice a day, Midodrine (treats low blood pressure) HCl 10 mg three times a day (hold if systolic (top number) blood pressure greater than 140), Entacapone (Parkinson medication) 200 mg four times a day, Colace (stool softener) 100 mg two daily, Cyanocobalamin 1000 mcg daily, Melatonin (sleep aid) 3 mg bedtime, Folic Acid 2 mg two tablets daily, Baclofen (muscle relaxant) 10 mg at bedtime, Cholecalciferol 1000 units 2-3 times a week, Senna (laxative) two tablets daily as needed, Linzess (irritable bowel medication) 72 mg daily. During an interview with RN 3 on 2/8/22 at 2:30 p.m., RN 3 stated she had not looked at his medications. During an interview with Director of Patient Care Services (DPCS) on 2/9/22 at 10:00 a.m., DPCS stated medications should be reviewed at every visit.

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 seven (Patients 1, 3, 5, 6, 10, 11 and 12) of 13 sampled patients, the home health agency (HHA) failed to meet the Condition of Participation for Care Planning, Coordination of Services, and Quality of Care when the agency licensed nursing staff did not follow the plan of care or notify the physician for changes in conditions.Refer to deficiencies G572, G588, G590 The cumulative severity and intensity of these deficiencies resulted in the failure of the facility to meet 484.60 Care Planning, Coordination, Quality of Care. Refer to deficiencies G572, G588, G590

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 did not provide services as outlined in the plan of care for seven of 13 sampled patients (Patients 1, 3, 5, 6,10,11 and 12). Nursing services were not provided as ordered, pain was not managed effectively and equipment was not ordered This failure resulted in unmet patient healthcare goals. During a clinical record review on 2/8/22 for Patient 5, the Plan of Care document showed a start of care date 11/26/21 with the current certification period 1/25/22 - 3/25/22. Diagnoses Parkinson’s disease, heart failure, chronic kidney disease, stroke, and diabetes. Patient had been receiving physical therapy services and experienced a fall with a subsequent skin tear on left forearm. Review of Physician Orders indicated order was received on 1/27/22 for skilled nursing services. Review of Skilled Nursing Initial Evaluation/Assessment indicated initial assessment was completed on 2/3/22. Interventions included wound care two times a week for three weeks. The Plan of Care was not updated to reflect the skilled nursing visits. During an interview with the Director of Patient Care Services (DPCS) on 2/8/22 at 10:40 a.m., DPCS stated the initial assessment should have been completed within 48 hours of receiving the order. DPCS stated the delay put Patient 5 at risk for a wound infection. During a review of the policy titled Provision of Care, Treatment, and Service, dated 11/20, the policy indicated the initial visit must be performed within 48 hours of the referral. During a clinical record review on 2/9/22 for Patient 10, the Plan of Care document showed a start of care date 1/19/22 with the current certification period 1/19/22- 3/19/22. Diagnoses included recent COVID infection, weakness, atrial fibrillation (irregular heartbeat), chronic kidney disease, high blood pressure, and diabetes. Goals included increase activity tolerance, identify ineffective pain control measures, and clear lung sounds with no signs of infection. During a review of Comprehensive Adult Assessment, Start of Care Version, dated 1/19/22, the assessment showed Patient 10 complained of dizziness, becoming short of breath walking more than 20 feet or going up stairs, has a cough, ineffective pain control reporting pain 6/10 on a daily basis, fatigues easily, and has decreased balance, endurance, and gait. There was no documentation that Resident 10 had any further visits. During a telephone interview with Patient 10 on 2/10/22 at 10:00 a.m., Patient 10 stated she did not decline the home visits but has only had one from the nurse on 1/19/22. During an interview with the DPCS on 2/9/22 at 2:30 p.m., DPCS stated Patient 10 could have a worsening in condition requiring hospitalization if not seen. During a clinical record review on 2/9/22 for Patient 11, the Plan of Care document showed a start of care date 12/17/21 with the current certification period 12/17/21 – 2/14/21. Diagnoses included cellulitis left lower leg, non-pressure chronic ulcer left lower leg, second degree heart block, heart failure, chronic kidney disease, pacemaker, and stimulant dependence. Goals included prevent wound infection and contamination, wound will show progress in healing, pain level will be improved to less than 3 on a 0-10 scale, and compliance with medication. Interventions included wound care and medication management. Services included three visits a week for three weeks starting 12/19/21, two visits a week for three weeks starting 1/9/22, two visits a week for three weeks starting 1/23/22 and one visit per week for three weeks starting 1/30/22. During a review of the Plan of Care under frequencies, the record was not updated to reflect the continuation of services for the weeks of 1/9/22, 1/23/22, and 1/30/22. Review of Nursing Visit Record showed visits on 12/20/21, 12/24/21, 12/27/21, 12/31/21, 1/3/21, 1/8/21, and 1/31/21. Review of the Inter-Office Communication Note dated 2/3/22 indicated care was being provided without an order. During a telephone interview with Patient 11 on 2/14/22 at 2:25 p.m., Patient 11 stated he had not had a visit in about 2 weeks and was told he needed to be recertified before visits could resume. During a clinical record review on 2/9/22 for Patient 12, the Plan of Care document showed a start of care date 11/21/22 with the current certification period 1/20/22- 3/20/22. Diagnoses included malignant neoplasm of the brain, high blood pressure, seizures, and open wound left great toe. Goals included to reduce unplanned hospital visits, monitor neurological changes and report to physician, compliance with medications to prevent seizures, and improve wound status. Interventions included neurological assessments, wound care, and medication management. Services included skilled nursing twice a week for three weeks starting on 1/23/22. Review of the Nursing Visit Records indicated there was only one visit the week of 1/31/22 and no documentation of the physician being notified. During an interview with the DPCS on 2/9/22 at 2:30 p.m., DPCS stated Patient 12 could have a high potential of hospitalization and worsening in condition. DPCS stated health care goals will not be met without visits. Record review on 2/7/2022 of the policy and procedure “Care Planning Process” dated 11/2020, showed the purpose was, “To provide clinical direction to clinicians providing direct patient care. The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment (485) and plans of care (all disciplines).” Review of the policy and procedure “DME Process” (not dated) showed DME (durable medical equipment) showed “DME orders should all be processed as urgent once received.” Record review on 2/7/2022 of the document “Plan of Care” showed Patient 1’s start of care was 1/14/2022 with the current certification period 1/14/2022 to 3/14/2022. Diagnoses included osteoarthritis of the knee and difficulty walking. Goals for care included a pain level of less than 2 out of 10 (10 being the highest level on the pain scale). Review of the document “Skilled Nursing Initial Evaluation/Assessment” dated 1/14/2022, showed Patient 1’s level of pain was 8 and “sharp” and had historically been managed with Tylenol. Review of the document “Nursing Visit Record” dated 1/19/2022, showed Patient 1’s pain was a level 4 and “sharp.” The current pain management was described as “Effective.” Review of the document “Nursing Visit Record” dated 1/24/2022 showed Patient 1’s pain was a level 8, “sharp” and the pain management was “Not effective.” Review of the nursing notes showed Patient 1 had pain in her shoulder and back lower legs and she had been “trying to get a telephone appointment with her pain management doctor.” There was no documentation which showed Registered Nurse 1 (RN1) called the doctor. In an interview on 2/7/2022 at 4:02 p.m., RN1 confirmed she had not notified the doctor. In an interview at 1:45 p.m. on 2/8/2022, the Director of Patient Care Services (DPCS) confirmed RN 1 had not taken the steps necessary to meet Patient 1’s goals for pain as outlined in the plan of care. Record review on 2/7/2022 of the document “Plan of Care” showed Patient 3’s start of care was 1/26/2022 with the current certification period 1/26/22 to 3/26/2022. Diagnoses included hypertension (high blood pressure). Interventions included notifying the physician if the systolic blood pressure (top number) is greater than 190 or less than 80 and the diastolic (lower number) is greater than 100 or less than 50. Services included skilled nursing visits 2 times per week for 2 weeks starting 1/26/2022. Review of the document “Start of Care Version” showed a nursing visit took place on 1/26/2022. The section “Significant Past Health History” showed Patient 3 was 89 years old with complaints of, “Shortness of breath for 2 days that was worsening.” She had been diagnosed with “CHF exacerbation.” (CHF: congestive heart failure) There were no further documented nursing visits for Patient 3. In an interview at 3:38 p.m. on 2/7/2022, the agency’s Director of Patient Care Services (DPCS) confirmed there was no documentation in the clinical record which showed Patient 3’s skilled nursing needs were met by the agency as outlined in the plan of care. In an interview on 2/8/2022 at 1:45 p.m., the DPCS stated it was important for staff to follow up with Patient 3 so they could monitor her vital signs in order to prevent a stroke or heart attack since she had high blood pressure. Patient 3 was not available for an interview. Record review on 2/8/2022 of the document “Plan of Care” showed Patient 6’s start of care was 12/13/2021 with the current certification period 12/13/2021 to 2/10/2022. Diagnoses included chronic obstructive pulmonary disease (lung disease). Respiratory goals included a decrease in dyspnea (shortness of breath), to be free of respiratory infections and be able to demonstrate deep breathing/coughing exercises. The section “DME” showed Patient 6 required the use of a hospital bed. Record review on 2/8/2022 of the document "Home Health Physician Orders" dated 12/28/2021, showed Patient 6 was discharged from nursing services effective 12/28/2021 but continued to receive PT (physical therapy) services. (PT: physical strengthening) Review of the document “Home Health Physician Orders” dated 1/30/2022 showed “Skilled nurse to evaluate and develop plan of care…to assess/evaluate co-morbid conditions including O2 (oxygen) use and cardiovascular concerns as well as assess skin integrity and other conditions that present themselves during this episode.” Review of the agency’s intercommunications notes dated 1/28/2022 showed the administrator had asked nursing staff to follow up with Patient 6 “ASAP” as Patient 6 had the beginning of “Heel sores on both feet…” There was no documentation in the clinical record which showed Patient 6 received further nursing visits. In a concurrent interview, the DPCS confirmed physician orders had been written for additional nursing services on 1/30/2022 which were not provided for Patient 6. In an interview on 2/8/2022 at 11:53 a.m. PT 1 stated Patient 6 had started to develop redness on his feet and she was concerned about further skin breakdown. PT 1 also expressed concerns about Patient 6’s oxygenation level since his “levels were low,” during her visits. She stated she had done all she could within the parameters of her role as a physical therapist but needed nursing to go in and perform full skin and respiratory assessments. PT 1 confirmed the order for nursing services had been written on 1/30/2022 and was not sure why nursing had not yet been involved and she had been asking that “Same question.” In an interview on 2/8/2022 at 2:11 p.m., Patient 6’s family member (Family Member 1) confirmed no nurse had visited since the order was written on 1/30/2022. She stated Patient 6 had “A lot going on” and his breathing was “Not good.” He was always out of breath and required oxygen when he got up to use the bathroom. Family Member 1 stated Patient 6 liked it when nursing made visits because he was a private person who only felt comfortable with nursing looking at his body and assessing his skin for any breakdown. In an interview on 2/9/2022 at 11:10 a.m., Patient 6 confirmed no nurse had visited since he was discharged on 1/28/2022. Patient 6 stated it would have been helpful if they had restarted the visits since his breathing had gotten worse, he had severe pain in his leg and had developed an open sore. During a home visit on 2/10/2022 at 9 a.m., Patient 6 was observed in bed. He appeared weak and had an oxygen canister sitting next to his bed. (machine used to provide oxygen). Patient 6 stated he had been struggling to understand how high he was able to go on his oxygen level administration. Registered Nurse 5 (RN 5) was observed telling Patient 6 he could not go higher than the 3 Liters he had been currently receiving because it would have to be “Checked with the doctor.” Patient 6 stated a friend had told him not to go too high because it was not good for someone with COPD. There was no hospital bed observed in the home. Patient 6 stated he was not aware that he was supposed to get a hospital bed. He stated having one would be helpful for his breathing because he had to sleep on several pillows. In an interview on 2/10/2022 at 12:24 p.m. the DPCS confirmed the plan of care showed Patient 6 required the use of a hospital bed which had never been ordered. “Administering oxygen for chronic obstructive pulmonary disease (COPD) is not without risk and it should be properly prescribed – in terms of flow rate and mode of delivery – like any other drug. Giving high concentrations of oxygen to hypoxaemic (low level of oxygen in the blood) patients with hypercapnia (excessive carbon dioxide in the blood) can result in individuals losing their hypoxic drive to breathe, with development of CO2 retention, respiratory acidosis (when the body cannot remove all of the carbon dioxide the body produces), and even death.” [Oxygen and Inhalers: Graeme P Currie; BMJ 2006 July 1; 333(7557); 34-36. Ncbi.nlm.nih.gov/pmc/articles/PMC1488761/]

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 seven of 13 sampled patients (Patients 1,3, 5, 6, 10, 11 and 12). In addition, the nursing visits were not provided as ordered. This failure resulted in unmet healthcare goals. Findings: Record review on 2/7/2022 of the policy and procedure “Care Planning Process” dated 11/2020, showed the “Plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care.” Record review on 2/7/2022 of the document “Plan of Care” showed Patient 1’s start of care was 1/14/2022 with the current certification period 1/14/2022 to 3/14/2022. Diagnoses included osteoarthritis of the knee and difficulty walking. Goals for care included a pain level of less than 2 out of 10 (10 being the highest level on the pain scale). Review of the document “Skilled Nursing Initial Evaluation/Assessment” dated 1142022, showed Patient 1’s level of pain was 8 and “sharp” and has historically been managed with Tylenol. Review of the document “Nursing Visit Record” dated 1/19/2022, showed Patient 1’s pain was a level 4 and “sharp.” The current pain management was described as “Effective.” Review of the document “Nursing Visit Record” dated 1/24/2022 showed Patient 1’s pain was a level 8, “sharp” and the pain management was “Not effective.” Review of the nursing notes showed Patient 1 had pain in her shoulder and back lower legs and she had been “trying to get a telephone appointment with her pain management doctor.” There was no documentation which showed the doctor had been notified. In an interview on 2/7/2022 at 4:02 p.m., RN1 confirmed she had not notified the doctor in order to appropriately treat Patient 1’s pain. In an interview at 1:45 p.m. on 2/8/2022, the Director of Patient Care Services (DPCS) stated RN1 should have notified the clinical supervisor and called the doctor and updated the plan of care to reflect the ineffective treatment. Record review on 2/7/2022 of the document “Plan of Care” showed Patient 3’s start of care was 1/26/2022 with the current certification period 1/26/22 to 3/26/2022. Diagnoses included hypertension (high blood pressure). Nursing visits were to take place twice per week for 2 weeks starting on 1/26/2022. Interventions included monitoring Patient 3’s blood pressure and assessing for signs and symptoms of heart disease. Review of the document “Start of Care Version” showed a nursing visit took place on 1/26/2022. The section “Significant Past Health History” showed Patient 3 was 89 years old with complaints of, “Shortness of breath for 2 days that was worsening.” She had been diagnosed with “CHF exacerbation.” (CHF: congestive heart failure) There were no further documented nursing visits for Patient 3. In an interview and concurrent record review at 3:38 p.m. on 2/7/2022, the agency’s Director of Patient Care Services (DPCS) confirmed there were no further nursing visits provided for Patient 3. Patient 3 was not available to be interviewed. In an interview at 1:45 p.m. on 2/8/2022, the DPCS confirmed there had been no update to the plan of care which showed Patient 3 had not received the services as ordered and was therefore not meeting her established healthcare goals. Record review on 2/8/2022 of the document “Plan of Care” showed Patient 6’s start of care was 12/13/2021 with the current certification period 12/13/2021 to 2/10/2022. Diagnoses included chronic obstructive pulmonary disease (lung disease). Respiratory goals included a decrease in dyspnea (shortness of breath), to be free of respiratory infections and be able to demonstrate deep breathing/coughing exercises. Record review on 2/8/2022 of the document "Home Health Physician Orders" dated 12/28/2021, showed Patient 6 was discharged from home health skilled nursing services on 12/28/2021 but continued with physical therapy (PT). (PT: physical strengthening) Review of the document “Home Health Physician Orders” dated 1/30/2022, showed “Skilled nurse to evaluate and develop plan of care…to assess/evaluate co-morbid conditions including O2 (oxygen) use and cardiovascular concerns as well as assess skin integrity and other conditions that present themselves during this episode.” There were no further documented nursing visits for Patient 6. In an interview at 1:45 p.m. on 2/8/2022, the DPCS confirmed there were no further visits. The DPCS stated it was important to follow up with someone with lung disease due to their high risk of a heart attack or stroke. He confirmed Patient 6’s plan of care had not been updated to reflect the lack of nursing services. During a clinical record review on 2/8/22 for Patient 5, the Plan of Care document showed a start of care date 11/26/21 with the current certification period 1/25/22 - 3/25/22. Diagnoses Parkinson’s disease, heart failure, chronic kidney disease, stroke, and diabetes. Patient had been receiving physical therapy services and experienced a fall with a subsequent skin tear on left forearm. Review of Physician Orders indicated order was received on 1/27/22 for skilled nursing services. Review of Skilled Nursing Initial Evaluation/Assessment indicated initial assessment was completed on 2/3/22. Interventions included wound care two times a week for three weeks. During an interview with the Director of Patient Care Services (DPCS) on 2/8/22 at 10:40 a.m., DPCS stated the initial assessment should have been completed within 48 hours of receiving the order. DPCS stated the delay put Patient 5 at risk for a wound infection. During a review of the policy titled Provision of Care, Treatment, and Service, dated 11/20, the policy indicated the initial visit must be performed within 48 hours of the referral. During a clinical record review on 2/9/22 for Patient 10, the Plan of Care document showed a start of care date 1/19/22 with the current certification period 1/19/22- 3/19/22. Diagnoses included recent COVID infection, weakness, atrial fibrillation (irregular heartbeat), chronic kidney disease, high blood pressure, and diabetes. Goals included increase activity tolerance, identify ineffective pain control measures, and clear lung sounds with no signs of infection. During a review of Comprehensive Adult Assessment, Start of Care Version, dated 1/19/22, the assessment showed Patient 10 complained of dizziness, becoming short of breath walking more than 20 feet or going up stairs, has a cough, ineffective pain control reporting pain 6/10 on a daily basis, fatigues easily, and has decreased balance, endurance, and gait. There was no documentation that Resident 10 had any further visits. During a telephone interview with Patient 10 on 2/10/22 at 10:00 a.m., Patient 10 stated she did not decline the home visits but has only had one from the nurse on 1/19/22. During an interview with the DPCS on 2/9/22 at 2:30 p.m., DPCS stated Patient 10 could have a worsening in condition requiring hospitalization if not seen. During a clinical record review on 2/9/22 for Patient 11, the Plan of Care document showed a start of care date 12/17/21 with the current certification period 12/17/21 – 2/14/21. Diagnoses included cellulitis left lower leg, non-pressure chronic ulcer left lower leg, second degree heart block, heart failure, chronic kidney disease, pacemaker, and stimulant dependence. Goals included prevent wound infection and contamination, wound will show progress in healing, pain level will be improved to less than 3 on a 0-10 scale, and compliance with medication. Interventions included wound care and medication management. Services included three visits a week for three weeks starting 12/19/21, two visits a week for three weeks starting 1/9/22, two visits a week for three weeks starting 1/23/22 and one visit per week for three weeks starting 1/30/22. During a review of the Plan of Care under frequencies, the record was not updated to reflect the continuation of services for the weeks of 1/9/22, 1/23/22, and 1/30/22. Review of Nursing Visit Record showed visits on 12/20/21, 12/24/21, 12/27/21, 12/31/21, 1/3/21, 1/8/21, and 1/31/21. Review of the Inter-Office Communication Note dated 2/3/22 indicated care was being provided without an order. During a telephone interview with Patient 11 on 2/14/22 at 2:25 p.m., Patient 11 stated he had not had a visit in about 2 weeks and was told he needed to be recertified before visits could resume. During a clinical record review on 2/9/22 for Patient 12, the Plan of Care document showed a start of care date 11/21/22 with the current certification period 1/20/22- 3/20/22. Diagnoses included malignant neoplasm of the brain, high blood pressure, seizures, and open wound left great toe. Goals included to reduce unplanned hospital visits, monitor neurological changes and report to physician, compliance with medications to prevent seizures, and improve wound status. Interventions included neurological assessments, wound care, and medication management. Services included skilled nursing twice a week for three weeks starting on 1/23/22. Review of the Nursing Visit Records indicated there was only one visit the week of 1/31/22 and no documentation of the physician being notified. During an interview with the DPCS on 2/9/22 at 2:30 p.m., DPCS stated Patient 12 could have a high potential of hospitalization and worsening in condition. DPCS stated health care goals will not be met without visits.

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’s licensed staff did not notify the doctor of a change of condition for three of 13 sampled patients (Patient 1, 3 and 6). Patient 1 had uncontrolled pain. Patients 3 and 6 did not receive the required nursing visits as outlined in the plan of care. These failures resulted in unnecessary pain for Patient 1. For Patients 3 and 6, their established healthcare goals were not met. Record review on 2/7/2022 of the policy and procedure (P&P), “Monitoring Patient’s Response/Reporting to Physician” dated 11/2020, showed, “Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress toward goals will be measured at regular intervals. Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.” Review of the P&P “Pain Assessment,” dated 11/2020 showed, “Pain that is not controlled with current regimen will be communicated to the physician to obtain orders for a more effective regimen.” Review on 2/7/2022 of the “Plan of Care” showed Patient 1’s start of care was 1/14/2022 with the current certification period 1/14/2022 to 3/14/2022. The diagnoses included osteoarthritis (wearing down of the cartilage tissue) of the knee and difficulty walking. The goals for care included a pain level of less than 2 out of 10 (10 being the highest level on the pain scale). Review of the “Skilled Nursing Initial Evaluation/Assessment,” dated 11/4/2022 showed, Patient 1’s level of pain was 8 and “sharp” and has historically been managed with Tylenol. Review of the “Nursing Visit Record” dated 1/19/2022, showed Patient 1’s pain was a level 4 and “sharp.” The current pain management was described as “Effective.” Review of the document “Nursing Visit Record” dated 1/24/2022 showed Patient 1’s pain was a level 8, “sharp” and the pain management was “Not effective.” Review of the nursing notes showed Patient 1 had pain in her shoulder and back lower legs and had been "trying to get a telephone appointment with her pain management doctor.” There was no documentation which showed Registered Nurse 1 (RN 1) called the doctor. In an interview on 2/7/2022 at 4:02 p.m., RN 1 confirmed she had not notified the doctor because she knew Patient 1 had been trying to make an appointment with her doctor. RN 1 stated she had told Patient 1 to “Call 911” if the pain did not improve. In an interview on 2/8/2022 at 1:45 p.m., the Director of Patient Care Services (DPCS) stated RN 1 should have notified the clinical supervisor and called the doctor. DPVS further stated the doctor should have been made aware the current pain control plan had not been working. Record review on 2/7/2022 of the “Plan of Care” showed Patient 3’s start of care was 1/26/2022 with the current certification period 1/26/22 to 3/26/2022. The diagnoses included hypertension (high blood pressure) and interventions included, notifying the physician if the systolic blood pressure (top number) is greater than 190 or less than 80 and the diastolic (lower number) is greater than 100 or less than 50. The services included skilled nursing visits 2 times per week for 2 weeks starting 1/26/2022. Review of the “Start of Care Version” showed a nursing visit took place on 1/26/2022. The “Significant Past Health History” showed Patient 3 was 89 years old with complaints of, “Shortness of breath for 2 days that was worsening.” She was diagnosed with “CHF (congestive heart failure) exacerbation.” There were no further documented nursing visits for Patient 3. In an interview on 2/7/2022at 3:38 p.m., DPCS confirmed there was no documentation in the clinical record which showed Patient 3’s skilled nursing needs were met by the agency as outlined in the plan of care and no call had been made to the doctor. Record review on 2/8/2022 of the "Plan of Care” showed Patient 6’s start of care was 12/13/2021 with the current certification period 12/13/2021 to 2/10/2022. The diagnoses included chronic obstructive pulmonary disease (lung disease) and the respiratory goals included, a decrease in dyspnea (shortness of breath), to be free of respiratory infections and be able to demonstrate deep breathing/coughing exercises. Record review on 2/8/2022 of the "Home Health Physician Orders" dated 12/28/2021, showed Patient 6 had been discharged from nursing services on 12/28/21. Patient 6 continued to receive physical therapy (PT) services. Review of the “Home Health Physician Orders” dated 1/30/2022 showed, “Skilled nurse to evaluate and develop plan of care…to assess/evaluate co-morbid (other disease/disorders) conditions including O2 (oxygen) use and cardiovascular concerns as well as assess skin integrity and other conditions that present themselves during this episode.” Record review on 2/8/2022 of the agency’s intercommunications notes dated 1/28/2022, showed the administrator had asked nursing staff to follow up with Patient 6 “ASAP” as Patient 6 had the beginning of “Heel sores on both feet…” There was no documentation in the clinical record which showed Patient 6 received further nursing visits or that the doctor had been notified. In a concurrent record review and interview on 2/8/22 at 11:40 a.m. DPCS confirmed physician orders had been written for additional nursing services on 1/30/2022 which were not provided for Patient 6 and the doctor was not notified.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to follow the requirements by the California Department of Public Health (CDPH) for vaccine requirement and testing for COVID-19. This deficient practice had the potential to infect vulnerable patients with the virus causing severe illness and possible death. During a review of the agency's policy, "Vaccination Policy: Mandatory," dated 1/10/22, the policy indicated an employee who is unvaccinated with an approved accommodation will be required to submit weekly test results. During a review of the CDPH All Facilities Letter (AFL) 21-34.2, issued on 1/26/22, the letter indicated CDPH is requiring health care providers (HCP) to be up to date with vaccinations and receive boosters by 3/1/22, unless exempt. COVID-19 testing must occur at least twice a week for unvaccinated exempt HCP (healthcare personnel) and booster-eligible HCP who have not yet received their booster in an acute care or long-term care setting and at least once weekly for HCP in other health care settings. During a review of the facilities vaccination records on 2/10/22, there were no records indicating the following HCP had received a booster or weekly COVID-19 testing for Registered Nurses (RN) 2, RN 5, RN 6, RN 7, Licensed Vocational Nurse (LVN) 1, Physical Therapists (PT) 1, PT 2, PT 3, PT 4, Physical Therapy Assistant (PTA) 1, Occupational Therapists (OT) 1, OT 2, Home Health Aid (HHA), and Registered Dietitian (RD) 1. During an interview with the Director of Patient Care Services (DPCS) on 2/10/22 at 12:15 p.m., DPCS stated only the exempt employees are being tested weekly. DPCS stated he was not aware of AFL 21-34.2 requiring weekly testing for those who had not received a booster.