Every finding on record at Prohealth Home Care, Inc

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 6/1/25 through 6/4/26. The agency reported 1757 unduplicated annual admissions. The patient sample size was 17 and 7 home visits were conducted.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure that their patient received home health services in accordance with the written individualized plan of care (POC) when staff did not reschedule a therapy missed visit for one out of 17 sampled patients (Patient 1). This failure had the potential to prevent Patient 1 from receiving needed home health treatments and services. Findings: A review of Patient 1's clinical records indicated Patient 1 had a start of care date with the Home Health Agency (HHA) on 5/8/26 and had diagnoses that included chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood) and diabetes mellitus (a chronic condition causing too much sugar in the blood). A review of Patient 1's plan of care, dated 5/8/26, indicated, "PT [Physical therapy] ...: 2 x week for 2 weeks starting 05/17/2026..." A review of Patient 1's schedule of PT visits for the week of 4/17/26, indicated Patient 1 had a PT missed visit on 5/20/26 and a PT visit on 5/21/26. A review of Patient 1's "PHYSICAL THERAPY PATIENT MISSED VISIT", dated 5/20/26, revealed that the PT missed visit on 5/20/26 was not rescheduled later in the week. During a concurrent interview and record review on 6/3/26 at 12:22 p.m. with the Director of Patient Care Services (DPCS), Patient 1's clinical record was reviewed. The DPCS confirmed that Patient 1 only received 1 PT visit for the week of 4/17/26 instead of 2 PT visits. The DPCS also confirmed that the 5/20/26 PT missed visit note did not indicate that there was an attempt to reschedule the visit later in the week. The DPCS stated the 5/20/26 missed visit should have been rescheduled to follow the ordered PT visit frequency. A review of the agency's policy and procedure titled, "MISSED VISITS", revised 7/2025, indicated, "...A missed visit will be rescheduled the same week if possible...1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit."

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure services and treatments were administered only as ordered by a physician or allowed practitioner for one out of 17 sampled patients (Patient 5). This failure resulted in the agency's inability to ensure that the patients' home health needs were coordinated and provided as ordered by a physician. Findings: A review of Patient 5's clinical records indicated Patient 5 had a start of care date with the Home Health Agency (HHA) on 3/20/26 and had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disorder and is the second most common type of progressive dementia), and prostate cancer. A review of Patient 5's physician orders titled, "HOME HEALTH PHYSICIAN ORDERS", dated 4/20/26, indicated, "Extension of PT (Physical Therapy) visit frequency...1 x week for 3 weeks starting 04/20/2026..." During a concurrent interview and record review on 6/3/26 at 12:22 p.m. with the Director of Patient Care Services (DPCS), Patient 5's clinical record was reviewed. The DPCS confirmed that Patient 5 received 1 PT visit for 4 weeks starting 4/20/26. The DPCS also confirmed that they only have an order for 1 PT visit for 3 weeks starting 4/20/26. The DPCS stated there should have been a physician's order for the extra visit of Patient 5. A review of the agency's policy and procedure titled, "PHYSICIAN PARTICIPATION IN PLAN OF CARE", revised 7/2025, indicated, "A physician will direct the care of every home health patient admitted for service. The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically necessary...8. Orders will be reviewed and revised by the patient's physician (or allowed practitioner) based on: A. Changes in the care or service being provided..."

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency did not ensure home health aide supervisory visits were completed within the required 14‑day timeframe for two of 17 sampled patients (Patient 12 and Patient 16). This failure had the potential to result in Patient 12’s and Patient 16’s treatment and personal care needs not being met. Findings: A review of Patient 12’s clinical record showed an SOC (Start of Care) date of 1/7/26 with diagnoses that included a pressure ulcer (damage to skin and tissue caused by pressure) to the right buttock. A review of Patient 16’s clinical record showed an SOC date of 4/29/26 with diagnoses that included a malig (malignant – invading local tissue) neoplasm (abnormal growth of tissue) of the head, face, and neck. During a concurrent interview and record review on 6/3/26 at 10:45 p.m., the DPCS (Director of Patient Care Services) confirmed Patient 12 received weekly skilled nursing and home health aide visits. The DPCS confirmed Patient 12 had a home health aide supervisory visit on 2/2/26 and again on 3/25/26, and stated supervisory visits were required every 14 days. Patient 12 missed two supervisory visits between 2/2/26 and 3/25/26. During a concurrent interview and record review on 6/3/26 at 2:55 p.m., the DPCS confirmed Patient 16 received weekly skilled nursing and home health aide visits. The DPCS confirmed Patient 16 had not received any home health aide supervisory visit since the SOC. The DPCS stated supervisory visits were required every 14 days per agency policy. During a review of the agency’s policy and procedure (P&P) titled, “Home Health Aide Plan of Care,” revised 7/2025, the P&P indicated, “The registered nurse or other appropriate clinician who is familiar with the patient, the patient’s plan of care and the written patient care instructions will complete a supervisory assessment of the home health aide no less frequently than every fourteen (14) days to ensure care is provided according to plan. The home health aide does not need to be present during the supervisory assessment.”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure discharge summaries were sent to their primary care practitioner (PCP) within 5 business days of their discharge from the agency and clinical records were completed timely for three out of 17 sampled patients (Patient 7, Patient 5, and Patient 3). These failures had the potential for Patient 7 and Patient 5 not to receive continuous treatment and care after their discharge from the agency and for Patient 3 to have an incomplete clinical record. 3. Review of Patient 3's clinical records indicated the patient had a start of care date of 4/10/26 and diagnoses included dysphagia (difficulty swallowing) and chronic kidney disease (a condition in which the kidneys are damaged and unable to filter blood efficiently). During a concurrent interview and record review of Patient 3’s clinical record on 6/3/26 at 1:39 p.m. with the Director of Patient Care Services (DPCS), it was confirmed that the Medical Social Worker (MSW) initial evaluation for Patient 3 was completed on 4/13/26 and the MSW documented a missed visit on 4/23/26. The DPCS confirmed the MSW had not conducted any further visits with Patient 3. During a follow-up interview with the DPCS on 6/3/26 at 2:26 p.m., the DPCS stated that after speaking with the MSW, the patient no longer wanted MSW services, and the MSW had completed a discharge summary as of 6/3/26. The DPCS stated she would expect MSW communication regarding the patient being discharged or not wanting any more services from MSW. A review of the agency’s P&P titled, “Discharge Summary,” revised 7/2025, indicated, “Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged…The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service.” 2. A review of Patient 5's clinical records indicated Patient 5 had a start of care date with the HHA on 3/20/26 and had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disorder and is the second most common type of progressive dementia), and prostate cancer. A review of Patient 5's discharge document titled, "OASIS PT [Physical Therapy] DISCHARGE", dated 5/14/26, indicated, Patient 5 was discharged from the agency on 5/14/26. During a concurrent interview and record review on 6/3/26 at 12:22 p.m. with the Director of Patient Care Services (DPCS), Patient 5's clinical record was reviewed. The DPCS confirmed that Patient 5 was discharged from their agency on 5/14/26. The DPCS also confirmed that Patient 5's discharge document was faxed to Patient 5's PCP on 5/22/26, which was more than 5 business days from Patient 5's discharge date. The DPCS stated that their policy was that the patient's discharge summary will be faxed to the PCP within 5 business days after their discharge from agency. A review of the agency's policy and procedure titled, "DISCHARGE SUMMARY", revised 7/2025, indicated, "Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record...3. A copy of the discharge summary will be provided to the patient's primary care practitioner, (or allowed practitioner) or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient's discharge." Findings: 1. A review of Patient 7's clinical records indicated Patient 7 had a start of care date of 2/2/26 and had diagnoses that included fracture of vertebra T9 and T10 (a break in the ninth and tenth bones of the thoracic [mid-back] spine), Rhabdomyolysis (a medical condition involving the rapid breakdown of damaged skeletal muscle), Hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormones), Hypertension (HTN-high blood pressure). A review of Patient 7's discharge document titled, "OASIS PT [Physical Therapy] DISCHARGE", dated 3/27/26, indicated, Patient 7 was discharged from the agency on 3/27/26. During a concurrent interview and record review on 6/3/26 at 2:55 p.m. with the Director of Patient Care Services (DPCS), Patient 7's clinical record was reviewed. The DPCS confirmed that Patient 7 was discharged from their agency on 3/27/26 and the discharge summary was never sent to the PCP. The DPCS stated the expectation was that the patient's discharge summary be faxed to the PCP within 5 business days after their discharge from agency.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure clinical records were completed timely for one out of 17 sampled patients (Patient 4). This failure created the potential for inaccurate or incomplete communication of treatment needs, risking unmet care needs and possible adverse events. Findings: A review of Patient 4's clinical records indicated Patient 4 had a start of care date on 4/20/26 and had diagnoses that included hemiplegia (partial or complete paralysis of one side of the body) following cerebral infarction (stroke) affecting left non dominating side. A review of Patient 4's Plan of Care (POC) for the certification period 4/20/26-6/18/26 included PT (Physical Therapy) services. Review of Patient 4’s clinical record included a “Physical Therapy Patient Missed Visit” note dated 4/28/26, which was blank. The record did not include: • An explanation for the missed visit • Documentation of how Patient 4's needs were addressed • Any assessment of the impact of the missed visit on the patient’s care. During a concurrent interview and record review on 6/2/26 at 9:26 AM, the Director of Patient Care Services (DPCS) confirmed that the 4/28/26 missed visit documentation had not been completed. The DPCS stated the missed visit form should be completed within 48 hours and that clinicians were expected to follow policy by communicating missed visits to the case manager and physician. A review of the agency's policy and procedure (P&P) titled, "Contents of the Clinical Record,” revised 7/2025, indicated, “The clinical record will contain sufficient information to identify the patient, describe the patient's problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel." A review of the agency’s P&P titled, “Missed Visits,” revised 7/2025, indicated, “To ensure that missed visits are documented and does not affect the quality of patient care…Missed visits will be communicated to the clinical supervisor and the patient's physician.”

The following reflects the findings of the California Department of Public Health during the investigation of complaint #100261 Representing the Department of Public Health: Health Facilities Evaluator Nurse, 38834 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the agency.

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, the Home Health Agency (HHA) failed to ensure the health and safety for one of three sampled patients were maintained, when the services were not performed as ordered by the physician and as documented in Patient 1’s Plan of Care (POC), which resulted in patient not receiving visits as ordered by the physician (G 572) and failure to communicate the discontinuation of services to Patient 1’s representative (G 598). The cumulative effect of these practices resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment. The cumulative effect of these practices resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment.

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, clinical record review, and policy and procedure review, the Home Health Agency (HHA) failed to follow the written plan of care (POC) for one of three sampled patients (Patient 1). The agency failed to notify the physician when the Patient 1’s catheter care was not provided due to missed visits and scheduled Patient 1’s visit without the physician order. In addition, the agency discharged the patient without documenting that POC goals were met. These failures resulted in Patient 1 not receiving the care and treatment the patient needed and placed him at risk to have a decline in his health status. According to the agency’s policy titled, “Care Planning Process,” dated 11/2020, the purpose of the policy was to “provide clinical direction to clinicians providing direct patient care.” The policy indicated that the care plan will be developed “based upon the patient’s identified needs …based upon the physician’s …orders …Services to be provided will be based on the prioritized needs of the patient …Care decisions and services to be provided will be made as a result of the care planning.” A review of Patient 1's clinical record indicated a SOC (start of care) date of 1/5/23, with primary diagnosis of obstructive and reflex uropathy (a disorder when urine cannot drain through the urinary tracts and urine backs up into the kidney causing kidney damage and exposing the ureters [tubes that drain urine from bladder] and kidney to infection). Patient 1’s other pertinent diagnoses indicated that the patient had dementia and Alzheimer's disease (impairment of cognitive [ability to think and reason] capacity to understand and make decisions). Due to this health condition, Patient 1 had a suprapubic catheter (a hollow flexible tube surgically implanted into the bladder through a cut into patient’s low abdominal wall to drain the urine). A review of Patient 1’s plan of care for the certification period of 1/5/23 through 3/5/23, included orders for SN (skilled nursing) visits for once a week for 5 weeks starting the week of 1/8/23 and ending the week of 2/11/23. The POC indicated that skilled nurses were to observe and assess Patient 1’s vital signs and body systems, focusing on genitourinary system and suprapubic catheter care. The POC indicated the SN were to assess the catheter and observe patient’s urine for signs and symptoms of infection. The nursing intervention directed clinicians to flush the catheter every week and as needed to prevent catheter clogging and to change the suprapubic catheter every month and as needed for leaking. The POC indicated that Patient 1 was homebound and required assistance to leave his residence due to weakness and safety issues. The Patient 1’s POC indicated the patient will be discharged from the services when the goals were met. Patient 1’s goal indicated that patient’s “urine elimination will be WNL [within normal limits] …catheter will remain …without complications … reduce [d] unplanned hospital or emergency department visits.” A review of Patient 1's visit calendar indicated there were a total of three visits completed by SN from 1/8/23 through 2/6/23. The calendar indicated the SN visits scheduled for 1/18/23 and 1/30/23 were not completed as ordered by the physician and Patient 1’s clinical records did not contain missed visits notes for these dates. There was no documented evidence Patient 1’s physician was notified that the SN visits were not conducted, and the patient’s weekly catheter care was not provided as ordered. Clinical records indicated that Patient 1 was discharged from the agency on 3/7/23, twenty-eight (28) days after his last SN visit. Further review of Patient 1’s clinical record indicated there were no physician orders for additional visits after the week of 2/11/23. However, Patient 1’s visit calendar indicated there was a SN visit scheduled for 2/20/23. Patient 1’s record contained a document titled, “Skilled Nursing Patient Missed Visit,” dated 2/20/23 and completed by SN 2. The missed visit note indicated, “Per family, Patient [1] went to ED [Emergency Department] yesterday [2/19/23] and catheter was changed.” There was no documented evidence that the agency contacted the patient's physician and obtained orders for additional visits for catheter care. A review of Patient 1’s clinical records did not indicate any documentation of coordination of care discussing the patient's emergency room visit. Review of the clinical notes dated from 1/5/23 to 3/7/23, revealed no notes from clinicians discussing the patient's suprapubic catheter care needs and his risk for infection. There was no documented evidence that during 28 days prior to discharge, skilled nurses or case manager visited and assessed Patient 1’s catheter, assured that his urine was free of signs and symptoms of infection, confirmed that the patient was knowledgeable about performing catheter care, and ready for the discharge. A review of Emergency Department (ED) physician notes dated 3/6/23 (a day before the patient was discharged from the HHA) indicated that the Patient 1 was brought to ED with blood in his catheter. The physician documented, "The patient states that the blood has been present for the last couple of days. He does describe some abdominal discomfort where he has a suprapubic catheter. He has also been short of breath for the past month. He has tried to use his asthma inhaler ...however he continuously runs out ...Patient's cousin is with him ...as he [Patient 1] has history of dementia." The physician documented that Patient 1's hematuria (blood in the urine) was due to underlying bladder infection. Per physician's notes, Patient 1's catheter was exchanged, and the patient was discharged home with antibiotics (medications to treat bladder infection). A review of ED physician notes dated 3/22/23, two (2) weeks after discharge from the agency, indicated that Patient 1 was brought to ED with blood in the catheter bag. The urine test was completed, and the patient was prescribed antibiotics to treat bladder infection. During a concurrent interview and record review on 7/26/23, commencing at 12:40 p.m., the Director of Patient Care Services (DPCS) acknowledged that Patient 1’s care plan was not followed. The DPCS confirmed there were no missed visits notes for the visit scheduled for 1/18/23 and 1/30/23. The DPCS was not able to find any documented evidence that Patient 1’s physician was informed that weekly catheter care was not completed as ordered. The DPCS stated her expectation was that SN 2 notified Patient 1’s physician and clinical managers about missed visits. The DPCS stated missed visits should be rescheduled for the same week, but they were not, and the patient missed his catheter care and genitourinary assessment. When discussing SN 2 documentation regarding ED visit, the DPCS acknowledged that Patient 1 might have had issues with his catheter due to previously missed visits. During a continued interview and record review with DPCS on 7/26/23, at 12:40 p.m., Patient 1's OASIS (Outcome and Assessment Information Set, a standardized data that contains information regarding the patient’s clinical condition, physical and mental status, living situation, and health care needs) non-visit discharge dated 3/7/23 was discussed. The DPCS explained that SN 1 completed Patient 1's discharge from the services over the phone without physically visiting and assessing the patient. The DPCS stated the documentation indicated that the phone call discharge was completed with the patient. The PDCS stated that the SN 1 should have contacted patient's son to inform that Patient 1 was discharged from the services. The DPCS was asked how the clinician determined that the patient's goals were met and the patient readiness for the discharge over the phone. The DPCS stated, "The nurse [SN 1] probably pulled his assessment from the previous assessment." The DPCS confirmed that Patient 1 was not assessed by clinicians for 28 days prior to discharge on 3/7/23 and that the patient's health condition might have changed. The DPCS confirmed that Patient 1's discharge OASIS did not address the genitourinary section, there was no urine description, and no indication if the patient's goal to be free of signs of infection was achieved. The DPCS stated that the SN 1 should have documented if Patient 1's POC specific goals were met before discharging him from the services instead of documenting "goals me.". During a follow up phone interview and record review on 8/9/23, at 3:25 p.m., the DPCS stated Patient 1’s POC was not revised and not updated and there was no physician order to continue visits after the week of 2/10/23. The DPCS stated, “The 2/20/23 visit should not have been scheduled. I don’t see additional new orders. This is a mess…The patient [Patient 1] should have been discharged on his last visit in February…” The DPCS did not provide any answer when asked if Patient 1's POC goals were met back in February on his last visit with SN 2. A review of the agency’s policy titled, “Missed Visits,” with the revision date of 11/2020, indicated, “PURPOSE: To ensure that missed visits are documented and does not affect the quality of patient care…Missed visits will be communicated to the clinical supervisor and the patient’s physician. A Missed visit will be rescheduled the same week. “ A review of the agency’s 'Reassessment/Recertification' policy, dated 11/2020, indicated, " The comprehensive assessment must be updated and revised ...to measure patient progress toward outcomes."

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to communicate patient’s discharge from the services to patient’s authorized representative (AR, a person responsible for making decisions on behalf of the patient) for one of three sampled patients (Patient 1). The agency did not communicate with AR regarding Patient 1’s discharge needs to reorder patient's medications. In addition, the agency failed to inform the AR to arrange appointments with Patient 1's urologist (a medical doctor specializing in treatment of bladder and kidneys problems) for follow up care after the patient’s discharge from the services. These failures placed Patient 1 at increased risk for decline in his health status and may have contributed to his frequent visits to the hospital after the discharge and death. A review of Patient 1's clinical record indicated a SOC (start of care) date of 1/5/23, with primary diagnosis of obstructive and reflex uropathy (a disorder when urine cannot drain through the urinary tracts and urine backs up into the kidney causing kidney damage and exposing the ureters (tubes that drain urine from bladder) and kidney to infection. Patient 1’s other pertinent diagnoses indicated that the patient had dementia and Alzheimer's disease (impairment of cognitive capacity to understand and make decisions). Due to his health condition, Patient 1 had a suprapubic catheter (a hollow flexible tube surgically implanted into the bladder through a cut into patient’s low abdominal wall to drain the urine). A review of Patient 1’s ‘Admission Consent’ dated 1/4/23 indicated that the consent was signed by Patient 1’s family member as an AR (authorized representative). A note at the bottom of consent indicated that Patient 1 was unable to sign the consent due to dementia. A review of Patient 1’s plan of care for certification period of 1/5/23 through 3/5/23, included orders for SN (skilled nursing) visits for once a week for 5 weeks starting the week of 1/8/23 and ending the week of 2/11/23. The POC indicated that skilled nurses were to observe and assess Patient 1’s vital signs and body systems, focusing on genitourinary system and suprapubic catheter care. The POC indicated the SN were to assess the catheter and observe patient’s urine for signs and symptoms of infection. The nursing intervention instructed clinicians to flush the catheter every week and as needed to prevent catheter clogging and to change the suprapubic catheter every month and as needed for leaking. The POC indicated that Patient 1 was homebound due to weakness and safety issues. Patient 1’s care plan goal indicated that patient’s catheter and urine will remain without complications, and unplanned hospital or emergency department visit will be reduced. A review of the admission Outcome and Assessment Information Set (Oasis, a standardized data that contains information regarding the patient’s clinical condition, physical and mental status, living situation, and health care needs) dated 1/5/23 indicated that Patient 1 required nurses to irrigate (flush) his catheter and change the catheter. A review of the Skilled Nursing Visit note dated 1/14/23, at 9:30 a.m., indicated, “Patient teaching done …patient has diagnosis of dementia and has trouble retaining information.” A review of the Skilled Nursing Visit note dated 2/6/23, at 11:36 a.m., SN 2 documented, “Teaching done on …Catheter care. Patient [1] has been using KY jelly lubricant to “clean’ area surrounding catheter insertion site. Advised patient that this is not a cleaning agent and is not necessary …Patient was not receptive to teaching today. He was argumentative and angry.” SN 2 documented that the plans for next visit will be “catheter assessment” and “catheter care teaching”. A review of Patient 1's Oasis RN (registered nurse, SN 1) Discharge assessment and discharge summary, dated 3/7/23, indicated the agency discharged the patient from their services. The Discharge Oasis indicated the patient’s discharge assessment was completed by SN 1 without physically visiting and assessing Patient 1. Patient 1’s clinical records indicated that the last time the patient’s suprapubic catheter was assessed was 2/6/23 during the visit by SN 2. There was no documented evidence that during 28 days prior to discharge on 3/7/23, the agency clinicians or case manager visited and assessed Patient 1’s catheter, assured that his urine was free of signs and symptoms of infection, and confirmed that the patient was knowledgeable about performing catheter care and ready for the discharge. In addition, the Oasis discharge summary indicated that Patient 1’s medications were not reviewed and not reconciled during his discharge and the medication list was not provided to the patient or patient’s representative. The discharge summary did not contain any information that the patient's AR was informed of the need to reorder patient's medications after the patient was discharged. The discharge Oasis assessment indicated that Patient 1’s cognitive and functional status did not change since his admission as he still required the same assistance with ambulation, transferring and he was homebound. The discharge Oasis summary dated 3/7/23 indicated that SN 1 did not contact Patient 1’s AR regarding the discharge needs but instead instructed Patient 1 who had impaired cognition “to follow up with his PCP [Primary Care Physician] and other specialties’. The section of discharge Oasis form titled, “Care Coordination,” dated 3/7/23 indicated the coordination details of “discharge from homecare” were not provided to Patient 1’s l legal representative. There was no documented evidence that the agency attempted to inform Patient 1’s AR to schedule catheter care and catheter change every month with his urologist. There was no documented evidence the agency contacted Patient 1’s urologist and arranged visits to conduct patient’s catheter change, catheter irrigation, and other catheter care. During a phone interview on 7/25/23, commencing at 1:10 p.m., Patient 1’s son, who was also Patient 1's AR, stated he was Patient 1’s “one and the only source for communication” due to his father’s impaired cognitive status. The AR stated he was furious that the agency nurses stopped services and did not inform him of his father’s discharge. Patient 1’s AR stated that after multiple phone calls to the agency he was informed that his father was discharged back in March because his objectives and goals were met. The AR stated, “I couldn’t comprehend how the objectives or goals were met if my father had suprapubic catheter for life and required catheter care weekly.” The AR added, “The whole point was to have HHA to come care for his catheter so he could stay at home. Father had dementia and according to person on the phone, the nurse communicated to my father that “the objectives were met” and he no longer was receiving services.” The AR stated that after the agency discontinued their services, his father had several Emergency Department (ED) visits related to urinary tract infection and later was admitted to the hospital with sepsis (a life-threatening condition due to untreated infection) related to urinary tract infection. The AR stated his father passed away 2 weeks after the admission and the physician indicated that his father died due to complications related to not receiving proper catheter care. During a concurrent interview and record review, commencing on 7/26/23, at 12:40 p.m., the Director of Patient Care Services (DPCS) acknowledged that Patient 1’s discharge planning and instructions were not communicated to patient’s authorized representative. The DPCS stated that it was inappropriate practice to give discharge instructions to the patient with cognitive impairment who was not receptive to teaching. The DPCS stated that Patient 1’s AR should have been involved in his father’s discharge and requirement to arrange post discharge follow up for patient’s catheter. The DPCS stated she did not recall if SN informed her or other clinical manager regarding patient’s discharge and his discharge needs. The DPCS stated that the agency should have set up appointment with Patient 1’s urologist for catheter care after the patient was discharged from the services. The DPCS confirmed that there were no records indicating that such arrangement was done prior to patient’s discharge. The DPCS searched the records and was unable to find any documentations that Patient 1’s discharge needs were discussed during care conferences. During a continued interview on 7/26/23, at 12:40 p.m., the DPCS stated that two weeks before any patient was discharged from their services, the agency clinicians would “discuss if goals were met and if not, the reasons why not met, discuss discharge needs and if discharge was appropriate.” The DPCS was asked if Patient 1’s POC goals and discharge needs were addressed during one of the care conferences. The DPCS provided a list of patients whose care needs were discussed during care conference in March of 2023, but the list did not have Patient 1’s name. The DPCS stated, “Patient [1’s] name is not a list. This was unplanned discharge, and we didn’t discuss patient’s needs.” The DPCS did not provide any answer to explain why Patient 1’s discharge was "unplanned" and added, “We didn’t discuss [Patient 1’s name] catheter and other discharge needs. With this patient I can only go by [SN 1's] documentation. It is not completed, and I was not able to talk to her about the documentation because she stopped responding to my calls.” During a follow up interview on 7/26/23, at 2:35 p.m., the DPCS acknowledged that Patient 1’s discharge “was not a safe discharge.” The DPCS stated that SN 1 did not contact Patient 1’s AR to address reordering patient’s medications before the HHA services were discontinued. The DPCS acknowledged that it was not safe practice to give discharge instructions to the patient who was not able to retain any information. During an interview on 7/26/23, at 2:50 p.m., Patient 1’s discharge was discussed with the Office Director (OD). The OD stated she was aware that Patient 1's discharge from the services was not communicated to AR and was “a 100 % not safe discharge." The OD stated the case manager should have arranged with AR the need to reorder patient's medications and should have contacted patient's urologist to arrange weekly catheter care and other catheter care needs. A review of the agency’s policy titled, “Discharge Criteria And Process,” dated 11/2020, indicated, “When the patient’s plan of care changes and this change results in discharge from services, the patient or his/her representative … will be notified and involved in planning decisions …The organization will verbally notify the patient of the decision to terminate …services within on (1) visit prior to the time the change in service is to occur (i.e., prior to the last scheduled visit) …For a patient requiring continuing care, assistance will be given to the patient and family/caregiver to manage continuing care needs after the organizational services are discontinued …Discharge planning will identify ongoing needs the patient may have. Arrangements for such services will be coordinated. The decision to terminate … services must be documented in the clinical record, citing …notification to the patient, the responsible family/caregiver or representative …The Clinical Supervisor ….is accountable for .... the required documentation.” A review of the agency’s policy titled, "Responsibilities/Supervision of Clinical Services," dated 11/2020 indicated, "The Clinical Director will oversee the day-to-day clinical operations ...The Clinical Director will be responsible for the clinical direction of the organization and will take reasonable steps to assure that ...care and services ...are coordinated and integrated ...Policies and procedures, which will guide and support the provision of care and services, are ...implemented."

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview and records review, the Home Health Agency (HHA) failed to ensure Skilled Nursing (SN) services for one of three sampled patients (Patient 1) were furnished in accordance with the plan of care and as ordered by patient’s physician (G 710), failed to coordinate services and communicate with all physicians involved in patient’s care (G 718), and failed to make an on-site supervisory visits every 30 days per agency’s policy (G726). The cumulative effects of these practices resulted in the failure of the agency to ensure the provision of quality health care in a safe environment.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure physician’s orders for catheter (drains urine from your bladder into a bag outside your body) care were followed for one of three sampled patients (Patient 1) when the patient did not receive catheter care every week as documented in his Plan of Care (POC). A review of Patient 1's clinical record indicated a SOC (start of care) date of 1/5/23, with a primary diagnosis of obstructive and reflex uropathy (a disorder when urine cannot drain through the urinary tracts and urine backs up into the kidney causing kidney damage causing kidney damage and exposing the ureters (tubes that drain urine from bladder) and kidney to infection. Due to his health condition, Patient 1 had a suprapubic catheter (a hollow flexible tube surgically implanted into the bladder through a cut into patient’s low abdominal wall to drain the urine). A review of Patient 1’s plan of care for certification period of 1/5/23 through 3/5/23, included orders for SN (skilled nursing) visits for once a week for 5 weeks starting the week of 1/8/23 and ending the week of 2/11/23. The POC indicated that skilled nurses were to focus on Patient 1’s genitourinary system and suprapubic catheter care. The POC indicated the SN were to assess the catheter and observe patient’s urine for signs and symptoms of infection. The nursing intervention indicated to flush the catheter every week and as needed for clogging and to change the suprapubic catheter every month and as needed for leaking. The Patient 1’s POC indicated that the goal for the patient was to “remain …without complications …[and] to reduce unplanned hospital or emergency department visits.” A review of Patient 1's visit calendar indicated that the SN visits scheduled for 1/18/23 and 1/30/23 were not completed as ordered by the physician. Additionally, Patient 1’s clinical records did not contain missed visits notes for 1/18/23 and 1/29/23 informing the physician that the SN visits were not conducted, and the patient’s weekly catheter care was provided as ordered. The missed visits were not rescheduled to be completed the same weeks to make sure that Patient 1’s catheter was flushed per physician order. During a concurrent interview and record review on 7/26/23, commencing at 12:40 p.m., the Director of Patient Care Services (DPCS) acknowledged that Patient 1’s plan of care regarding catheter care was not followed. The DPCS was not able to find any documented evidence that Patient 1’s physician was informed that weekly catheter care was not completed as ordered. The DPCS stated her expectation was that SN 2 notified Patient 1’s physician and clinical managers about missed visits and missed services. A review of the agency’s policy titled, “Missed Visits,” dated 11/20, indicated, “Missed visits will be communicated to …the patient’s physician. A missed visit will be rescheduled the same week if possible …The clinical supervisor will track the number and reasons for missed visits to assess patterns and assure that the plan of care contains the correct number of planned visits.”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to assure clinicians communicated and coordinated the plan of care (POC) with the physician for one of three sampled patients (Patient 1), when the agency did not report to Patient 1’s physician that weekly catheter care was not completed as ordered and failed to coordinate with the patient's primary care physician and urologist (a doctor specializing in treatment of bladder and kidneys problems) the patient’s post-discharge catheter care. These failures resulted in no follow up of patient’s catheter care needs and placed the resident’s health at risk. A review of the agency’s ‘Care Coordination’ policy dated 11/20 indicated the purpose of the policy was to ensure the coordination of services for each patient and to minimize the potential for missed services. According to the policy, “timely and ongoing communication was the responsibility of each team member and should be appropriate to the needs of the patient and relevant to the care provided …Care coordination will include …regularly occurring …communication among team members …communication with all physicians involved in the plan of care …coordination of care delivery to meet the patient’s needs, and involve the patient, representatives …Organization personnel will communicate changes in a timely manner via telephone, one-to-one meetings, care conferences and home visits. Documentation of all communications will be included in the clinical record …will include: the date and time of the communication, individuals involved with the communication, information discussed… The clinicians will be responsible for facilitating communications …” A review of Patient 1's Plan of Care (POC) for certification period of 1/5/23 through 3/5/23, indicated a primary diagnosis of obstructive and reflex uropathy (a disorder when urine cannot drain through the urinary tracts and urine backs up into the kidney causing kidney damage and exposing the ureters (tubes that drain urine from bladder) and kidney to infection. Due to his health condition, Patient 1 had a suprapubic catheter (a hollow flexible tube surgically implanted into the bladder through a cut into patient’s low abdominal wall to drain the urine). A review of Patient 1’s POC for certification period of 1/5/23 through 3/5/23, included orders for SN (skilled nursing) visits for once a week for 5 weeks starting the week of 1/8/23 and ending the week of 2/11/23. The POC indicated that skilled nurses were to focus on Patient 1’s genitourinary system and suprapubic catheter care. The POC indicated the SN were to assess the catheter and observe patient’s urine for signs and symptoms of infection. The nursing intervention indicated to flush the catheter every week and as needed for clogging and to change the suprapubic catheter every month and as needed for leaking. The Patient 1’s POC goal indicated that the patient’s “urinary elimination will be normal …catheter will remain …without complications …[and] to reduce unplanned hospital or emergency department visits.” A review of Patient 1's visit calendar indicated that the SN visits scheduled for 1/18/23 and 1/30/23 were not completed as ordered by the physician. Patient 1’s clinical records did not contain care coordination notes for 1/18/23 and 1/29/23 informing patient’s physician, case manager or clinical supervisor that the patient’s weekly catheter care was not provided as ordered. A review of Patient 1’s clinical records indicated that the patient was discharged from the services 3/7/23, two days after the end of certification period. Patient 1’s clinical records did not contain any documentation that the patient’s discharge needs for catheter care and medications reordering were communicated among his clinicians during care conferences. There was no documented evidence the agency contacted Patient 1’s primary physician and urologist and arranged visits to conduct patient’s catheter change, catheter irrigation, and other catheter care upon his discharge from the services. During a concurrent interview and record review on 7/26/23, commencing at 12:40 p.m., the Director of Patient Care Services (DPCS) confirmed there were no missed visits notes for the visit scheduled for 1/18/23 and 1/29/23. The DPCS was not able to find any documented evidence that Patient 1’s physician was informed that weekly catheter care was not completed as ordered. The DPCS stated her expectation was that SN 2 notified Patient 1’s physician regarding missed visits. The DPCS stated missed visits should be rescheduled for the same week, but they were not, and the patient missed his catheter care which placed him at risk for infection and clogging of the catheter. The DPCS stated that the agency should have set up appointment with Patient 1’s urologist for catheter care after the patient was discharged from the services. The DPCS confirmed that there were no records indicating that such arrangement was done prior patient’s discharging and agreed that this placed Patient 1’s health at risk for harm. A review of the agency’s policy titled, “Discharge Criteria and Process,” dated 11/20, indicated, “When the patient’s plan of care changes and this change results in discharge from services… his/her primary physician will be notified and involved in planning decisions… For a patient requiring continuing care, assistance will be given to the patient and family/caregiver to manage continuing care needs after the organizational services are discontinued …Discharge planning will identify ongoing needs the patient may have. Arrangements for such services will be coordinated …Action taken must be documented in the clinical record …The Clinical Supervisor ….is accountable for ... the required documentation.” A review of the agency’s policy titled, "Responsibilities/Supervision of Clinical Services," dated 11/20 indicated, "The Clinical Director will oversee the day-to-day clinical operations ...The Clinical Director will be responsible for the clinical direction of the organization and will take reasonable steps to assure that ...care and services ...are coordinated and integrated ...Policies and procedures, which will guide and support the provision of care and services, are ...implemented."

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to furnish skilled nursing (SN) services under the supervision of a Registered Nurse (RN) to ensure quality of care was provided for one of three sampled patients (Patient 1) and the care provided by licensed vocational nurse (LVN) SN 2 was not supervised by RN when Patient 1 had missed SN visits, was not assessed for signs and symptoms of infection, and his catheter care were not completed as ordered. This failure resulted in care for Patient 1 not being evaluated to ensure the patient’s care needs were met and placed the patient at an increased potential of complications related to care. A review of Patient 1's clinical record indicated a SOC (start of care) date of 1/5/23, with diagnoses which included obstructive and reflex uropathy (a disorder when urine cannot drain through the urinary tracts and urine backs up into the kidney causing kidney damage and exposing the ureters (tubes that drain urine from bladder) and kidney to infection. Due to his health condition, Patient 1 had a suprapubic catheter (a hollow flexible tube surgically implanted into the bladder through a cut into patient’s low abdominal wall to drain the urine). A review of Patient 1’s plan of care for certification period of 1/5/23 through 3/5/23, included orders for SN (skilled nursing) visits for once a week for 5 weeks starting the week of 1/8/23 and ending the week of 2/11/23. The POC indicated that skilled nurses were to focus on Patient 1’s genitourinary system and suprapubic catheter care. The POC indicated the SN were to assess the catheter and observe patient’s urine for signs and symptoms of infection. The nursing intervention indicated to flush the catheter every week and as needed for clogging and to change the suprapubic catheter every month and as needed for leaking. The Patient 1’s POC indicated that the goal for the patient was to “remain …without complications …[and] to reduce unplanned hospital or emergency department visits.” A review of Patient 1's visit calendar indicated there were a total of three visits completed by SN 2 from 1/8/23 through 2/6/23. The calendar indicated the SN visits scheduled for 1/18/23 and 1/30/23 were not completed as ordered by the physician and Patient 1’s clinical records did not contain missed visits notes for these dates. The missed visits were not rescheduled to be completed the same weeks to make sure that Patient 1’s catheter was flushed per physician order and urine assessed for signs of infection. Clinical records indicated that Patient 1 was discharged from the agency on 3/7/23, twenty-eight (28) days after his last SN visit. A review of Patient 1’s clinical records failed to reveal any documentation of coordination of care between clinicians assigned to Patient 1 discussing the patient's emergency room visit. Review of the clinical notes dated from 1/5/23 to 3/7/23, revealed no notes from clinicians discussing the patient's suprapubic catheter care needs and his risk for infection. There was no documented evidence that during 28 days prior to discharge, skilled nurses and/or case manager visited and assessed Patient 1’s catheter, assured that his urine was free of signs and symptoms of infection, confirmed that the patient was knowledgeable about performing catheter care, and ready for the discharge. A review of Emergency Department (ED) physician notes dated 3/6/23 (a day before the patient was discharged from the HHA) indicated that the Patient 1 was brought to ED with blood in his catheter. The physician documented, "The patient states that the blood has been present for the last couple of days. He does describe some abdominal discomfort where he has a suprapubic catheter." The physician documented that Patient 1's hematuria (blood in the urine) was due to underlying bladder infection. Per physician's notes, Patient 1's catheter was exchanged, and the patient was discharged home with antibiotics (medications to treat bladder infection). A review of ED physician notes dated 3/22/23, two (2) weeks after discharge from the agency, indicated that Patient 1 was brought to ED with blood in the catheter bag. The urine test was completed, and the patient was prescribed antibiotics to treat bladder infection. During a concurrent interview and record review on 7/26/23, commencing at 12:40 p.m., the Director of Patient Care Services (DPCS) stated that RN supervisory visits should be done every 30 days. The DPCS reviewed Patient 1’s clinical records and stated the supervisory visit should have been done on 2/5 or 2/6/23. The DPCS stated the purpose of RN supervisory visits was to ensure patient’s care plan was followed, that all of patient’s needs were addressed, and the patient received quality care. The DPCS stated that Patient 1 had one (1) visit by RN at the SOC in January 2023. The DPCS did not answer when asked if Patient 1 received quality care when there was no RN oversight for his care. A review of the agency's 'Responsibilities/Supervision of Clinical Services,' policy dated 11/20, indicated, "PURPOSE: To ensure a process is in place for the selection of a qualified individual for overseeing all clinical care and services ...The Clinical Director will be responsible for the clinical direction of the organization ...The Clinical Director will ensure that the following supervision is maintained within the organization ...LVN will be supervised by a registered nurse (RN) at least every 30 days ...Supervisory visits will be made more often if indicated by the patient's and or organization personnel's need."

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 6/20/23 through 6/22/23. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 36681 HFEN, 32096 HFEN, 32525 HFEN, 45718 HFEN, 45882 The agency reported 2879 unduplicated annual admissions. The patient sample size was 18 and 7 home visits were conducted. The Department was unable to substantiate a violation of the Emergency Preparedness regulations.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 6/20/23 through 6/22/23. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 36681 HFEN, 32096 HFEN, 32525 HFEN, 45718 HFEN, 45882 The agency reported 2879 unduplicated annual admissions. The patient sample size was 18 and 7 home visits were conducted.

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 clinical record review, the agency failed to ensure one of 18 sampled patients (Patient 9) was assessed for her immediate care and support needs when the Start of Care (SOC) date was delayed for three weeks from the initial referral date. This failure resulted in delayed identification of Patient 9's care needs which placed the patient at increased risk of her health and safety. Findings: Patient 9 had a SOC date of 5/2/23 with diagnoses that included impairment of brain function and generalized weakness with advanced age. Review of Patient 9's clinical records included as follows: 4/12/23: An initial Medical Doctor (MD) referral for home health services for skilled nursing (SN) and physical therapy (PT) 4/21/23: The 2nd referral by the MD for home health services for SN, PT and occupational therapy 5/2/23: SOC assessment conducted by a Registered Nurse Review of the agency's policy and procedure, Intake Process, revised November 2020, stipulated, "...schedule an assessment visit. This initial visit will be performed either within 48 hours of the referral, or within 48 hours of a patient's return home, or on the start of care date ordered by the physician..." This policy indicated to notify MD for a delay in providing services, "If services cannot be provided and or there is a delay in providing services, Clinical supervisors will notify MD or non-admission and/or delay in start of service. (sic) intake personnel will give the caller the names of other agencies than can provide the required services." Review of Patient 9's clinical record included no documented evidence the patient's physician was notified the delayed service after the 2nd referral or the agency provided the names of other agencies that could serve the patient. In an interview on 6/22/23 at 12:04 p.m., the Administrator acknowledged the service was delayed for Patient 9 and verified the physician was not notified and there was no documentation about the delayed SOC in the patient's clinical record. The Administrator stated the service should have started within 48 hours of the referral.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on interview, clinical record and policy and procedure review, the agency failed to ensure the initial assessment was performed within 48 hours of referral by a skilled professional (Physical Therapist- PT) for one of 18 sampled patients (Patient 10). This failure resulted in 7 days delay in providing PT services for Patient 10 and had the potential risk for decline in mobility. Findings: A review of Patient 10’s physician orders dated 6/16/23 indicated she had a surgical repair of the right leg on 5/19/23, was discharged and returned home on 5/26/23. She was on non-weight bearing status to the right lower extremity, was not able to walk and was using a wheelchair for mobility. Patient 10’s referral documents reviewed indicated she was referred to the agency for PT services on 6/8/23. The name of her physician was documented on the referral document including his telephone number. A review of Patient 10’s ‘Inter-office Communication Notes’ indicated the agency was aware of the patient’s primary physician on 6/8/23. The agency staff contacted the patient’s family on 6/9/23 and the family indicated they were ready to start the PT services. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 6/21/23, at 2:25 p.m., she validated the agency was aware of Patient 10’s primary physician on 6/8/23 and had contacted the family on 6/9/23. The DPCS stated the PT should have gone out to assess the patient by 6/10/23 or sooner. The DPCS validated there was no documented evidence the physician was notified of the delay in the start of care and the patient was not seen by PT until 6/16/23. This represented 7 days delay in assessment and start of care and services. A review of the agency’s policy and procedure titled, “Provision of Care, Treatment, and Service” dated 10/2020 indicated, “An initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist … on all patients referred. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home …”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to notify the physician of missed visits for two of 18 (Patient 6 and Patient 18) sampled patients. These failures had the potential to delay the patient's progression of care. A review of Patient 18’s Plan of Care (POC) indicated he was admitted on 6/13/23 with multiple diagnoses which included Hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke, a death in brain tissue). A review of Patient 18’s Referral notes dated 6/11/23 at 10:45 a.m., indicated, “Order: CONSULT TO HOME HEALTH…Reason for Consult: HHRN (Home Health Registered Nurse) PT (Physical Therapist) OT (Occupational Therapist) MSW (Medical Social Worker)…” A review of Patient 18’s Physician’s order signed 6/15/23 indicated, “FREQUENCIES …Active…MSW: (Eval) 1 x week for 1 week starting 06/13/2023…Start Date: 06/13/2023 End Date: 06/17/2023…” A review of Patient 18’s Calendar for MSW visit indicated, MSW Evaluation was not done on the week of 6/13/23-6/17/23. During a concurrent interview and record review on 6/21/23 at 11:45 a.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed that MSW evaluation was ordered for Patient 18 but was not done. She stated, “they’re (MSW) supposed to go within 5 days and they are supposed to communicate the reason why the visit is not done and notify the doctor…” She further stated, missing the MSW evaluation could negatively impact the patient’s care. The DPCS confirmed, there was no documented evidence in Patient 18's clinical records of the reasons why he was not seen by the MSW. A review of the agency’s policy titled “Provision of Care, Treatment and Service, MISSED VISITS" revised 11/20 indicated, “Missed visits will be communicated to the clinical supervisor and the patient's physician…Missed visits will be documented in the clinical record…” Findings: A review of Patient 6’s clinical record indicated a Start of Care (SOC) of 5/11/23 with diagnoses including malignant neoplasm (cancer) of unspecified part of right bronchus or lung. Review of Patient 6’s Plan of Care (POC) indicated an order for PT/PTA (Physical Therapy/Physical Therapy Assistant) visit one time a week for one week starting 5/12/23. Further review of Patient 6’s clinical record indicated a missed visit note signed by the PT on 5/13/23. The comments indicated, “Reschedule PT Eval for following week due to pt [Patient 6] unavailable because of cancer treatments.” There was no documented evidence the physician was informed of Patient 6’s missed visit. A concurrent interview and record review was conducted on 6/22/23 at 10:06 a.m. The Director of Patient Care Services (DPCS) confirmed Patient 6 had a missed visit on 5/12/23 and their policy is to notify the physician for missed visit. In a follow-up interview on 6/22/23 at 11:38 a.m., the DPCS stated her expectation was for the PT to inform the physician of Patient 6’s missed visit. A review of the agency’s policy and procedure revised November 2020 and titled, “MISSED VISITS” indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician…If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained…notify the physician …of the missed visit…”

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on observation, interview, and clinical record review, the agency failed to revise one of 18 sampled patients (Patient 9's) care plan for home health aide (HHA) services when the patient's care needs had changed. This failure resulted in Patient 9's changing care needs not being accurately reflected in the care plan and had the potential for misleading clinicians in evaluating the effectiveness and relevance of the care plan to meet the needs of the patient. Findings: Patient 9 was a female patient with a Start of Care (SOC) date 5/2/23 with diagnoses that included impairment of brain function and generalized weakness with advanced age. Review of Patient 9's Plan of Care, dated 5/3/23, included a physician order for HHA home visit once a week for 10 weeks starting 5/3/23. During a home visit conducted on 6/21/23 starting at 10 a.m., HHA 1 was observed providing a partial bed bath to Patient 9. Review of the HHA care plan, dated 5/2/23, for Patient 9 included tasks for HHA to provide oral care, shave with electric razor and exercises per physical therapy (PT) which were not performed during the home visit observation. In an interview on 6/21/23 at 10:45 a.m., HHA 1 stated she had never provided oral care for the patient as the patient's daughter completed the oral care before the patient's breakfast prior to her visit. HHA 1 stated she did not shave or use electric razor for the patient as she was a female patient. HHA 1 stated she did not know what the PT exercises were for the patient. HHA 1 stated the care plan was not updated as it included the tasks no longer provided. In a telephone interview on 6/22/23 at 10:29 a.m., HHA 1 stated Patient 9 was an elderly patient and stated she did not like to get out of the bed to do exercise. HHA 1 stated she reported about the oral care and the patient did not want to get out of the bed to the patient's nurse before and again on 6/21/23 after the home visit. HHA 1 stated licensed nurse should have updated the care plan. Review of the agency's policy and procedure, Care Planning Process, revised November 2020, stipulated, "The plan of care will be revised as frequently as deemed necessary by the clinician based on the ongoing assessment of the patient...the review of the plan of care will based on changes in the patient's health status, needs, and the environment factors affecting care." In an interview on 6/22/23 at 11:15 a.m., the Administrator verified the HHA care plan for Patient 9 and acknowledged the HHA care plan did not reflect accurately the patient's needs and stated the care plan should have been revised to meet the ongoing changing needs of the patient.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a home health aide supervisory visit was conducted within the 14-day timeframe for one of 18 (Patient 11) sampled patients. This failure had the potential for Patient 11's plan of care not to be followed or updated. Findings: A review of Patient 11’s clinical record indicated a Start of Care (SOC) date of 5/30/23 with diagnoses including encounter for surgical aftercare following surgery on the digestive system. Further review of Patient 11's clinical record indicated a Plan of Care (POC) from 5/30/23 to 7/28/23. The POC included an order for Home Health Aide (HHA) one time a week starting 5/30/23 and Registered Nurse/Licensed Vocational Nurse (RN/LVN) twice a week for two weeks starting 5/30/23. A concurrent interview and record review was conducted on 6/21/23 at 9:41 a.m. The Director of Patient Care Services (DPCS) confirmed Patient 11 had orders for HHA and skilled nursing. The DPCS stated the HHA visit for Patient 11 started on 5/31/23, and the RN conducted home visits on 6/12 and 6/19/23. The DPCS confirmed the skilled nursing visit note dated 6/12/23 and 6/19/23 did not include a supervisory visit note. The DPCS stated there should have been a supervisory visit conducted by the registered nurse on 6/12/23, within 14 days. The DPCS further stated, “she [RN] did not do it”. A review of the agency’s policy and procedure revised November 2020 and titled, “HOME HEALTH AIDE SUPERVISORY VISITS” indicated, “…The registered nurse or other appropriate skilled professional that is familiar with the patient, the patient’s plan of care, and the written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals…The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted at least every fourteen (14) days or less if the patient is receiving skilled services…Supervisory visits and overall supervision will be documented in the clinical record.”

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 clinical record review, the agency failed to maintain accurate and complete clinical records for two of 18 sampled patients (Patient 9 and Patient 5) when: 1. Inaccurate information was recorded for Patient 9, and 2. Care related email communications were not included in Patient 5's clinical record. Theses failures placed the patients at risk for unmet care needs and had the potential for misleading health professionals in making health care decisions for the patients. 2. Patient 5's plan of care was reviewed and indicated she was admitted to the agency on 1/19/23 with diagnoses of fracture lumbar spine (lower backbone) and pelvis (lower part of the torso). According to Patient 5’s referral documents, she was discharged from the hospital on 1/10/23 and was referred to the agency for nursing, physical and occupational therapy services. A review of Patient 5’s ‘Inter-office Communication Notes’ indicated the agency accepted her with a start of care date of 1/11/23 and the agency staff had spoken to the family on 1/7/23. The agency had called the family again on 1/13/23 and left a message. A review of Patient 5’s plan of care dated 1/19/23 indicated her care did not start until 1/19/23. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 6/21/23, at 2:25 p.m., the DPCS was asked why Patient 5’s start of care was delayed. The DPCS stated the patient’s record had no documented reason for the delay. The DPCS opened her emails and stated the patient went back to the hospital soon after discharge and did not return home until 1/17/23. The DPCS stated this information was not entered in the patient’s record. The DPCS further stated the Case Managers, and the intake staff should have entered this information in Patient 5’s record. The DPCS validated the last communication note by the agency staff was on 1/13/23. A review of the agency’s policy and procedure titled, ‘Contents of the Clinical Record’ dated 11/2020 indicated, “A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information … facilitate continuity of care among organization and contract personnel … Documentation of communication to the organization receiving the patient when he/she is transferred … Documentation of telecommunication services …” Findings: Patient 9 was a female patient with a Start of Care (SOC) date 5/2/23 who had diagnoses that included impairment of brain function and generalized weakness with advanced age. Review of Patient 9's OASIS RN START OF CARE assessment on 5/2/23 by Skilled Nurse (SN) 1 included the SN 1's narrative notes in the Assessment Summary, "SOC DONE FOR A [patient's age] YEAR OLD MALE REFFERED TO..." describing the patient was a male. A home visit was conducted on 6/21/23 at 10 a.m. for an onsite observation of the home health aide (HHA) services for Patient 9. Review of the HHA care plan, dated 5/2/23, for Patient 9 included tasks to provide oral care, shave with electric razor and exercises per physical therapy (PT) which were not performed during the home visit observation. In an interview on 6/21/23 at 10:45 a.m., HHA 1 stated she had never provided oral care for the patient as the patient's daughter completed the oral care before the patient's breakfast prior to her visit. HHA 1 stated she did not shave or use electric razor for the patient as she was a female patient. HHA 1 stated she did not know what the PT exercises were for the patient therefore had not performed them. HHA 1 stated she always indicated Patient 9 "refused" in those items when she documented her HHA visit notes. Review of Home Health Aide (HHA) Visit Notes for 5/24/23, 5/29/23, 6/7/23, and 6/13/23 showed all tasks assigned in the care plan including oral care, shave with electric razor and exercises per physical therapy for Patient 9 were check marked indicating those tasks were performed on each visit. In a telephone interview on 6/22/23 at 10:29 a.m., HHA 1 acknowledged her visits notes were inaccurate and stated, "Maybe I mistakenly check marked them." Review of the agency's policy and procedure, Entries into the Clinical Record, revised November 2020, stipulated, "...the medical record should accurately reflect a clear account of the patient's entire course of care." In an interview on 3/22/23 at 11:15 a.m., the Administrator verified the inaccuracy of the Initial assessment and the HHA visit notes. The Administrator acknowledged the inaccurate sex identification of the patient in the initial assessment could have led to create the irrelevant task in the HHA care plan to shave the patient with electric razor. The Administrator stated patient's clinical records should be accurate to avoid potential miscommunication among disciplines and acknowledged inaccurate clinical records could negatively affect health professionals in making health care decisions for the patient.

The following reflects the findings of the California Department of Public Health during the investigation of complaints #CA00722375. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 32525 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the agency.

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 agency failed to ensure the Plan of Care (POC) contained the services ordered by the referring physician for one of 3 sampled patients (Patient 1) when an order for Home Health (HH) Aide was not included. This failure resulted in Patient 1 not receiving HH Aide care for 19 days and had the potential to result in deterioration of his personal care needs. Findings: According to Patient 1's POC, dated 1/9/21 through 3/9/21, he had multiple diagnoses which included right buttock pressure sore and paraplegia (paralysis to the lower part of the body due to spinal cord injury). The plan of care did not contain orders for HH Aide. A review of Patient 1's 'Referral Summary' dated 12/4/20 with a fax date of 1/8/21 indicated the services ordered included HH Aide. A review of Patient 1's physician 'Face to Face Attestation' dated 8/3/20 indicated the services of a HH Aide was 'Medically Necessary' for personal care services including bathing. According to Patient 1's 'Client Coordination Note Report' documented as a 'Late Entry For 12/9/20' and faxed to the Department on 1/28/21, a HH Aide started visiting him on 1/27/21. This represented 19 days of missed services since the agency received the fax order on 1/8/21. During an interview with Licensed Nurse (LN) 1 on 1/28/21 at 9:40 a.m., she stated she should have included the services of a HH Aide in Patient 1's POC as ordered by the physician. LN 1 stated Patient 1 needed assistance with bathing, showering, bowel care, repositioning, and personal hygiene. LN 1 further stated she was not sure an Aide would be available to provide the care as the prior Aide was on vacation. A review of the agency's 'Care Planning Process' policy dated 11/2020 indicated, "To provide clinical direction to the clinicians providing direct patient care ... Based on the assessment and conclusions, the plan of care will include, but not limited to: ... Specific services and treatments to be provided ... The plan of care will be based upon the physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies, and services required to meet the patient's needs." An interview conducted with the Director of Patient Care Services (DPCS) on 1/28/21 at 11:27 a.m., she stated, LN 1 should have communicated to the agency regarding the need for a HH Aide for Patient 1 and included the aide services on his plan of care. The DPCS stated LN 1 should have notified Patient 1's physician when the Aide services were not provided for 19 days.

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 agency failed to ensure the physician was notified of changes in the plan of care when services ordered for Home Health (HH) Aide were not provided as ordered for 19 days for one of 3 sampled patients (Patient 1). This failure had the potential to result in decline in Patient 1's health condition when personal care needs were not met. Findings: According to Patient 1's POC dated 1/9/21 through 3/9/21, he had multiple diagnoses which included right buttock pressure sore and paraplegia (paralysis to the lower part of the body due to spinal cord injury). The plan of care did not contain orders for HH Aide services. A review of Patient 1's 'Referral Summary' dated 12/4/20 with a fax date of 1/8/21 indicated the services ordered included HH Aide. A review of Patient 1's physician 'Face to Face Attestation' dated 8/3/20 indicated the services of a HH Aide was 'Medically Necessary' for personal care services including bathing. According to Patient 1's 'Client Coordination Note Report' documented as a 'Late Entry For 12/9/20' and faxed to the Department on 1/28/21, a HH Aide started visiting him on 1/27/21. This represented 19 days of missed services since the agency received the physician fax order on 1/8/21. During an interview with Licensed Nurse (LN) 1 on 1/28/21 at 9:40 a.m., she stated she should have included the services of a HH Aide in Patient 1's POC as ordered by the physician. LN 1 stated Patient 1 needed assistance with bathing, showering, bowel care, repositioning, and personal hygiene. LN 1 further stated she was not sure an Aide would be available to provide the care as the prior Aide was on vacation. A review of the agency's 'Care Planning Process' policy dated 11/2020 indicated, "To provide clinical direction to the clinicians providing direct patient care ... Based on the assessment and conclusions, the plan of care will include, but not limited to: ... Specific services and treatments to be provided ... The plan of care will be based upon the physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies, and services required to meet the patient's needs ...Clinician's will inform the patient's physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes. An interview conducted with the Director of Patient Care Services (DPCS) on 1/28/21 at 11:27 a.m., she stated LN 1 should have communicated to the agency regarding the need for a HH Aide for Patient 1 and included the aide services on his plan of care. The DPCS stated LN 1 should have notified Patient 1's physician when the Aide services were not provided for 19 days.

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 clinical record review, the agency failed to ensure care coordination notes were documented in a timely manner for one of 3 sampled patients (Patient 1) when notes were entered late. This failure had the potential to negatively impact Patient 1's continuity of care. Findings: According to Patient 1's plan of care (POC) dated, 1/9/21 through 3/9/21 and a Start of Care (SOC) dated 1/9/21, he had multiple diagnoses which included right buttock pressure sore and paraplegia (paralysis to the lower part of the body due to spinal cord injury). Patient 1 was receiving Skilled Nurse (SN) visits 5 times a week. A prior POC dated 12/2/20 through 1/30/21 indicated Patient 1's SOC was on 8/4/20. According to an 'Intake Information' received by the Department on 1/22/21 indicated, '... they haven't provided a single caregiver this year.' During a review of Patient 1's clinical record on 1/27/21 starting at 12:11 p.m. concurrently with the Director of Patient Care Services (DPCS), there was no documented evidence why Patient 1's SOC date had changed from 8/4/20 to 1/9/21, no documentation why services of a Home Health Aide were not being offered and why services of a Social Worker had not been offered to assist patient with outside resources including hiring a private care-giver. Further review of Patient 1's clinical record indicated: A 'Late Entry' untimed coordination note with three entries, two for 1/13/21 and one for 1/15/21 and had been updated by a nurse on 1/26/21 at 5:21 p.m. The 1/15/21 note indicated Patient 1 had been seen previously by another agency and had refused the services of a social worker. This represented 12 and 10 days respectively of late documentation. A 'Late Entry' untimed coordination note for 12/9/21. The note date indicated 1/27/21 and reflected the nurse had seen Patient 1 on 12/8/20 and he had verbalized not wanting a certain HH Aide. The note also indicated another HH Aide had started providing care for Patient I on 1/27/21. This represented 48 days of late documentation. A 'Late Entry' untimed coordination note for 12/31/21 which was documented on 1/27/21. The note indicated Patient 1 had a change of insurance and a new SOC would be initiated after the authorization process. This represented 26 days of late documentation. During an interview with Licensed Nurse (LN) 1 on 1/28/21 at 9:40 a.m., she stated documentation should be completed during or after home visit. A review of the agency's 'Entries into the Clinical Record' policy dated 11/2020 indicated, "The date and time requirement applies to all entries in the record and the medical record should accurately reflect a clear account of the patient's entire course of care. Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday and clinical notes dictated or written will be incorporated into the patient's health record at least every seven working days. The clinical note will include ... Signature of clinician and his/her credentials." An interview conducted with the Director of Patient Care Services (DPCS) on 4/13/21 at 4:32 p.m., she stated the coordination notes for Patient 1 should have been completed within 24 hours as per policy.

The following reflects the findings of the California Department of Public Health during the investigation of complaint#CA00701940. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 32525 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the agency.

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- ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to initiate care within 48 hours of a patient's referral or discharge from the hospital for 2 of 5 sampled patients (Patient 2 and Patient 3) as required by the regulations. This failure had the potential for the patients care needs not to be met in a timely manner and resulted in Patient 3's admission to the hospital due to a critical abnormal laboratory (lab) result that put him at very high risk of bleeding. Findings: 1. According to the Plan of Care (POC) for Patient 2, the agency admitted him for home care services on 7/23/2020 with diagnoses of multiple pressure ulcers for wound care, paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and was dependent on wheelchair. A review of Patient 2's 'Inter-Office Communication Note' indicated a referral was received by the agency from the acute hospital on 7/17/2020 and he was discharged from the hospital on 7/20/20. The note indicated the agency had received a call from the hospital asking if Patient 2 can be seen on 7/20/20. The note indicated Patient 2 had called the agency on 7/20/20 and reported his care-giver had become homeless over the weekend and had not come on 7/20/20. The note indicated the Start of Care (SOC) visit was scheduled for 7/21/20. A review of Patient 2's assessment dated, 7/23/20, indicated the Registered Nurse (RN) initiated care on 7/23/20. There was no documented reason for the delay in SOC for Patient 2. A review of the agency's 'Admission Criteria Process' dated 10/2015 indicated, "To establish standards and a process by which a patient can be evaluated and accepted for admission ... The Clinical Supervisor will assign clinical organization personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from a referring facility. The initial visit must be performed either within 48 hours of referral, within 48 hours of patient's return home, or on the start of care date ordered by the physician ..." During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 8/21/20, at 12:15 p.m., she stated there was no documentation why Patient 2 was not seen on 7/21/20. The DPCS stated Patient 2 should have been seen within 48 hours as per policy. The DPCS stated there was no documented evidence the physician was notified of the delay in SOC. 2. A review of Patient 3's home health order from the hospital dated 8/1/20 indicated under special instructions that she should have INR (international normalized ratio, a lab test used to monitor blood thinning medications) in 2 days after discharge and 2-3 times per week and call the results to the Coumadin (a blood thinner medication that requires regular lab tests to determine dosage adjustments) clinic. The INR was to be maintained between 2.5 to 3.5. According to the POC with a start of care date of 8/12/20, Patient 3 was admitted to the agency following an open heart surgery. The POC also included a physician order for Coumadin to prevent clot formation. A review of Patient 3's 'Inter-Office Communication Note' indicated a referral was received by the agency from the acute hospital on 8/2/20 and authorization to provide skilled nursing and physical therapy received on 8/5/20 (The day the patient was discharged from the hospital). The notes indicated a visit was scheduled for 8/10/20 and Patient 3's family had called the agency to ask what time the RN would be visiting because they needed to know the instructions for the medication Coumadin. A staff from the agency called Patient 3's family on 8/11/20 asking them to take her to the emergency room for a lab draw. The note dated 8/16/20 indicated Patient 3 had a high INR of greater than 8.0 when the RN visited for the SOC on 8/12/20 and was admitted to the hospital on 8/13/20 and was still at the hospital on 8/15/20. Patient 3's INR was at a critically high level that put her at risk for excessive bleeding which could result in a stroke or death. A review of the agency's 'Admission Criteria Process' dated 10/2015 indicated, "To establish standards and a process by which a patient can be evaluated and accepted for admission ... The Clinical Supervisor will assign clinical organization personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from a referring facility. The initial visit must be performed either within 48 hours of referral, within 48 hours of patient's return home, or on the start of care date ordered by the physician ..." During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 8/21/20, at 12:15 p.m., she stated Patient 3 should have been seen within 48 hours or earlier to complete the INR lab draw and as per policy. The DPCS stated there was no documented evidence the physician was notified of Patient 3's delay in SOC and delay in INR lab draw.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was notified of missed visits for one of 5 sampled patients (Patient 1) when there was no documented evidence the visits were made. This failure had the potential for Patient 1's care needs to not be met. Findings: According to Patient 1's Plan of Care (POC), she was admitted for home care services on 6/30/2020. The POC indicated the Skilled Nurse (SN) was to visit 2 times a week for 4 weeks to assess his respiratory status, wound care for lower extremities and medication management. A review of the SN visit notes reflected no visits were made between 7/2/2020 through 7/23/2020, a period of over 2 weeks. A review of the agency's 'MISSED VISITS' policy dated 4/2017 indicated, " To ensure that missed visits are documented and does not affect the quality of care. Missed visits will be communicated to the clinical supervisor and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record." During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 8/21/2020, at 12:15 p.m., she stated the nurse assigned to Patient 1 should have documented why the visits were missed and documented physician notification of missed visits

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(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 clinical record review and interview, the agency failed to notify the physician of delay in care for 2 of 5 sampled patients (Patient 2 and Patient 3 ) when there was no documented evidence of physician notification. This failure had the potential for the patient's care needs not to be reviewed by the physician in a timely manner. Findings: 1. According to the Plan of Care (POC) for Patient 2, the agency admitted him for home care services on 7/23/2020 with diagnoses of multiple pressure ulcers for wound care, paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and was dependent on wheelchair. A review of Patient 2's 'Inter-Office Communication Note' indicated a referral was received by the agency from the acute hospital on 7/17/2020 and he was discharged from the hospital on 7/20/20. The note indicated the agency had received a call from the hospital asking if Patient 2 can be seen on 7/20/20. The note indicated Patient 2 had called the agency on 7/20/20 and reported his care-giver had become homeless over the weekend and had not come on 7/20/20. The note indicated the start of Care (SOC) visit was scheduled for 7/21/20. A review of Patient 2's assessment dated, 7/23/20, indicated the Registered Nurse (RN) initiated care on 7/23/20. There was no documented reason for the delay in SOC for Patient 2 or a physician notification of the delay. A review of the agency's 'Admission Criteria Process' dated 10/2015 indicated, "To establish standards and a process by which a patient can be evaluated and accepted for admission ... The Clinical Supervisor will assign clinical organization personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from a referring facility. The initial visit must be performed either within 48 hours of referral, within 48 hours of patient's return home, or on the start of care date ordered by the physician ..." During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 8/21/20 at 12:15 p.m., she stated there was no documentation why Patient 2 was not seen on 7/21/20. The DPCS stated Patient 2 should have been seen within 48 hours as per policy. The DPCS stated there was no documented evidence the physician was notified of the delay in SOC. 2. A review of Patient 3's home health order from the hospital dated 8/1/20 indicated under special instructions that she should have INR ((international normalized ratio, a lab test used to monitor blood thinning medications) in 2 days after discharge and 2-3 times per week and call the results to the Coumadin (a blood thinner medication that requires regular lab tests to determine dosage adjustments) clinic. The INR was to be maintained between 2.5 to 3.5. According to the POC with a start of care date of 8/12/20, Patient 3 was admitted to the agency following an open heart surgery. The POC also included a physician order for Coumadin to prevent clot formation. A review of Patient 3's 'Inter-Office Communication Note' indicated a referral was received by the agency from the acute hospital on 8/2/20 and authorization to provide skilled nursing and physical therapy received on 8/5/20 (The day the patient was discharged from the hospital). The notes indicated a visit was scheduled for 8/10/20 (seven days after referral) and Patient 3's family had called the agency to ask what time the RN would be visiting because they needed to know the instructions of the medication Coumadin. A staff from the agency called Patient 3's family on 8/11/20 asking them to take her to the emergency room for a lab draw. The note dated 8/16/20 indicated Patient 3 had a high INR of greater than 8.0 when the RN visited for the SOC on 8/12/20 (10 days after referral) and was admitted to the hospital on 8/13/20 and was still at the hospital on 8/15/20. This resulted in a 6 day delay in drawing the blood sample. Patient 3's INR was at a critically high level that put her at risk for excessive bleeding which could result in a stroke or death. A review of the agency's 'Admission Criteria Process' dated 10/2015 indicated, "To establish standards and a process by which a patient can be evaluated and accepted for admission ... The Clinical Supervisor will assign clinical organization personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from a referring facility. The initial visit must be performed either within 48 hours of referral, within 48 hours of patient's return home, or on the start of care date ordered by the physician ..." During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 8/21/20, at 12:15 p.m., she stated Patient 3 should have been seen within 48 hours or earlier to complete the INR lab draw and as per policy. The DPCS stated there was no documented evidence the physician was notified of Patient 3's delay in SOC and delay in INR lab draw.