Every finding on record at Prospect Home Healthcare, Inc.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey on 8/20/2024 to 8/23/2024 at the unapproved address on record: 15643 Sherman Way, Van Nuys, CA 91406. Complaint Number: 109029 Active Census: 0 Discharged: 103 Sample Size: 7 Home Visits: 3 Closed Records: 4 On 8/20/2024 at 4:40 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) related to the Home Health Agency (HHA) failure to safeguard clinical records of 103 of 103 discharged patients from unauthorized access. As a result, the noncompliance had the potential to result in an unauthorized access and use of patients’ protected health information (PHI, any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) and loss of clinical records. On 8/20/2024 at 5 p.m., the survey team requested the HHA to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 8/23/2024 at 4:05 p.m., the Department called a second IJ in the presence of the agency’s Office Staff 1 and Office Staff 2, related to the HHA's failure to ensure the clinical records for comprehensive assessment, skilled nurse visits, and discharge assessment were complete and consistent for one of seven sampled patients (Patient 6). The Administrator was not available when calling an IJ. As a result, the noncompliance resulted in the HHA providing care without assessing and identifying the needs of Patient 6 which likely to cause unidentified needs, serious injury and could lead to hospitalization and death. On 8/23/2024 at 5:20 p.m., the Department called a third IJ in the presence of the Administrator Designee (AD) related to the HHA’s failure to ensure to complete the comprehensive assessment at discharge and provide discharge notification/instructions for one of seven sampled patients (Patient 6). As a result, the non-compliance had the potential to result in Patient 6’s discharge without reflecting patient’s current health status, without informing Patient 6 of the status of her home health services and without discharge instructions regarding the continuity of her care which could lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:25 p.m., the Department called a fourth IJ in the presence of the AD related to the HHA’s failure to ensure the Director of Patient Care Services (DPCSD) and the Administrator (ADM), acting as the governing body, assumed full responsibility for the day-to-day operation of the HHA and provision of care for two of seven sampled patients (Patient 1 and Patient 6). As a result, the noncompliance had the potential to result in disruption of patient care and services and in Patient 1 and Patient 6 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:32 p.m., the HHA did not provide an IJ removal plan, and the AD stated the HHA would be closed (for business) and will no longer be opened. The survey team was unable to complete the survey tasks. On 8/23/2024 at 5:35 p.m., the HHA did not submit an IJ removal plan for the four IJs. The survey team left with the IJ not removed. As of 9/6/2024, the HHA did not submit an IJ removal plan for the four IJs. The following Conditions of Participation (COP) were not met: 484.50 Condition of Participation: Patient rights 484.55 Condition of Participation: Comprehensive Assessment of Patients 484.105 Organization/Administration Services 484.110 Clinical Records .

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA 2, [HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence]) failed to ensure the Condition of Participation regarding Patient’s Rights was met when: 1. The HHA failed to ensure to provide written notice of the patient’s rights and responsibilities which included transfer and discharge policies/notification, were provided to two of seven sampled patients (Patient 1 and Patient 6). (Refer to G 412). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal regulations for Patient’s Rights to ensure patients were provided discharge notification and notification was understandable.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA 2, [HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure to provide written notice of the patient’s rights and responsibilities which included transfer and discharge policies/notification, were provided to two of seven sampled patients (Patient 1 and Patient 6). This deficient practice resulted in patients not knowing and/or understanding about their discharge from HHA which had the potential to affect their quality of life and care. a. During a review of Patient 1’s "Patient Information", the "Patient Information" indicated Patient 1 was admitted to the HHA 2 on 4/9/2024 with a primary diagnosis of primary generalized osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time, causing bones to rub together). During a review of Patient 1’s "Home Health Certification and Plan of Care (a document outlining the timeframe when patient will be receiving home health services, the types of home health services and items needed by the patient, the frequency of the services, and the predicted outcomes of treatment/services)" for the certification period of 6/8/2024 to 8/6/2024, the "Home Health Certification and Plan of Care" indicated Patient 1 was receiving Skilled Nurse (SN) service once a week for one week, twice a week for the following two weeks, and once a week for the remaining six weeks. The "Home Health Certification and Plan of Care" indicated that Physical Therapist would evaluate patient to determine the frequency needed. During a joint home visit to Patient 1’s residence on 8/21/2024 at 12:30 p.m. with Registered Nurse 2 (RN 2), Patient 1 was observed alert, oriented, and ambulatory (able to walk, not bedridden). During an interview on 8/21/2024, at 12:43 p.m., with Patient 1 in her native language (Russian), Patient 1 stated she had been a patient of HHA 2 for more than three years. Patient 1 stated that she had been visited by a nurse and a physical therapist from HHA 2 once a week. Patient 1 stated the nurse would check her temperature, blood pressure, and pain level during the visits, and help her with medication refills. Patient 1 stated she had been receiving physical therapy for her shoulders. According to Patient 1, she had arthritis (redness and swelling/inflammation in a joint) in both of her shoulders which was causing pain and stiffness. Patient 1 stated the last time she was seen by the physical therapist the day before on 8/20/2024 and by the nurse the previous week. Asked Patient 1 if she knew that she was discharged from HHA 2 on 7/26/2024. Patient 2 stated she had not been discharged from HHA 2 because she was just visited by the physical therapist on 8/20/2024 and the physical therapist did not notify her that she would be discharged. Patient 2 stated the HHA 2's nurse did not inform her that she would be discharged when she visited last week (unable to recall the date). During an interview and record review on 8/21/2023, at 1 p.m., in Patient 1's residence, Patient 1’s home folder from HHA 2 was reviewed. Inside the home folder, observed a copy of "Patient Discharge Instructions/Notification", dated 7/26/2024. The "Patient Discharge Instructions/Notification" form had Patient 1’s name and Patient 1’s signature. The form also had Registered Nurse 1’s (RN 1) signature on the "Professional Signature Line". The "Special Instructions and Significant Telephone Numbers" section was blank. Patient 1 confirmed that it was her signature on the "Patient Discharge Instructions/Notification" form. Patient 1 stated she did not understand what was written on the "Patient Discharge Instructions/Notification" form, because it was written in English. Patient 1 stated she signed the form because the nurse asked her to sign. Patient 1 stated she did not remember when she signed the form. A review of Patient 1’s "Skilled Nursing Visit" note, completed by the Licensed Vocational Nurse 1 (LVN 1), dated 7/22/2024, the "Skilled Nursing Visit" note indicated that discharge instructions were given. A telephone call was made to LVN 1 on 8/23/2024 at 1:58 p.m. and left message. The phone call was not answered nor call was returned. During an interview on 8/20/2024 at 2:50 p.m. with the Administrator (ADM), the ADM stated the HHA 2 did not have any active patients at the time of the interview and visit. The ADM stated that she was the administrator of four HHAs owned by her mother: HHA 1, HHA 2, HHA 3, and HHA 4. According to the ADM, her mother was currently sick and was undergoing treatment in overseas. The ADM stated she decided to discharge all patients from HHA 1, HHA 2, HHA 3, and HHA 4, so she could focus on taking care of her mother. The ADM stated none of the patients from HHA 2 were referred to another HHA for their continuing health care needs. The ADM did not provide an answer on how HHA 2 could ensure the discharged patients’ home care needs would be met after the discharge. A review of HHA 2’s undated policy and procedure (P&P), titled “Discharge Planning, Transfer, and Continuing Care Needs,” the P&P indicated the following: - The staff member should prepare the patient for discharge by instructing the patient/caregiver to perform necessary care or should work making alternative plans for continuing care when further health care is needed. The agency will work with the physician and patient/caregiver in arranging continuing care of the patient. - Patients are informed prior to discharge of plans for discharge and the reason for discharge. During a review of Patient 6’s “Patient Information” (undated), the "Patient Information" indicated a start of care date of 8/6/2024 with a primary diagnosis of “Other intervertebral disc degeneration (an age-related disorder due to the loss of disk height, increased disk bulging and subsequent pressure on nerve roots that lead to chronic back pain) Lumbar Region (lower back region of backbone)”. During a review of Patient 6’s “Home Health Certification and Plan of Care”, with a certification period from 8/6/2024 to 10/4/2024, the “Home Health Certification and Plan of Care” indicated the following for Patient 6: - Skilled nurse (SN) visits twice a week for two weeks, then once a week for seven weeks. - Patient 6 was a “homebound status, leaving home requires a considerable and taxing effort for the patient. Specify: Patient is confined because of illness, impaired mobility, prone to fall, unsteady gait, uncontrolled blood pressure (the force against blood vessel walls as the heart pumps blood), using of assistive devices, daily pain, taxing efforts to leave home unassisted.” - Discharge plans included: “Discharge when medical condition is stable and patient is no longer in need of skilled services. Discharge to care of physician. Discharge when caregiver willing and able to manage all aspects of patient’s care and discharge when goal is met.” During a review of Patient 6’s Outcome and Assessment Information Set, (OASIS, a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients) Discharge,” dated 8/10/2024, the “OASIS Discharge” indicated the Director of Patient Care Services (DPCS) conducted the assessment for Patient 6, but did not sign nor date the assessment. During a home visit on 8/21/2024, at 11:12 a.m., at Patient 6's residence, reviewed Patient 6’s HHA 2's folder (patient information, medication list, and services being provided) with Patient 6. The translator was used to communicate with Patient 6 in her native language in Armenian during home visit. Patient 6 stated she was discharged from HHA 3 on 7/27/2024. Patient 6 stated she did not know she was admitted to HHA 2 and did not know about HHA 2. Patient 6 stated since she was discharged from HHA 3 on 7/27/2024, no nurse visited her from any HHA. Patient 6 presented HHA 3 folder and did not have any documents from HHA 2. The survey team attempted to interview DPCS on 8/21/2024, at 12:40 p.m., the DPCS was not available and was on vacation. The agency had no DPCS designee since June 2024. During a concurrent interview and record review on 8/22/2024, at 12:30 p.m., with the ADM and the Office Staff 2 (OS 2), Patient 6’s “OASIS – Discharge,” dated 8/10/2024, was reviewed. The “OASIS - Discharge" of Patient 6 indicated, the documentation was not complete, and the DPCS did not sign and has no date in the documentation. The ADM and OS 2 stated Patient 6’s “OASIS – Discharge” assessment was incomplete and was not done, the DPCS did not sign, and there was no date in the document. The ADM stated she did not know what happened to Patient 6, and she was confused to answer to the question. The ADM stated the DPCS would come tomorrow and would be able to answer the questions. During an interview on 8/23/2024 at 11:47 a.m. with the ADM, the ADM stated, the DPCS was not answering her telephone calls and she went on a two-week vacation since last week. The ADM stated, she sent her Administrator Assistant (AA) to the DPCS’s residence, but no one was there. The ADM stated she needed to travel out of the country to attend to a family emergency.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence, rather than in a more traditional healthcare facility setting) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: The HHA failed to ensure to conduct a complete comprehensive assessment at the time of discharge and to provide a copy of discharge notification/discharge instructions to one of seven sampled patients (Patient 6). (Refer to G 550). The cumulative effect of the systemic practice resulted in the HHA providing care without assessing and identifying patient’s needs that can potentially affect patients’ care and services and may lead to hospitalization and death.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence, rather than in a more traditional healthcare facility setting) failed to conduct and document an accurate comprehensive assessment at the time of discharge to one of seven sampled patients (Patient 6). This failure resulted in Patient 6 was being discharged from HHA without patient’s knowledge and without evaluation of Patient 6’s current overall health status that could lead to harm, hospitalization, and death. On 8/23/2024 at 5:20 p.m., the Department called a third IJ in the presence of the Administrator Designee (AD) related to the HHA’s failure to ensure to complete the comprehensive assessment at discharge and provide discharge notification/instructions for one of seven sampled patients (Patient 6). As a result, the non-compliance had the potential to result in Patient 6’s discharge without reflecting patient’s current health status, without informing Patient 6 of the status of her home health services and without discharge instructions regarding the continuity of her care which could lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:32 p.m., the HHA did not provide an IJ removal plan, and the AD stated the HHA would be closed (for business) and will no longer be opened. The survey team was unable to complete the survey tasks. On 8/23/2024 at 5:35 p.m., the HHA did not submit an IJ removal plan. The survey team left with the IJ not removed. . Findings: A review of Patient 6’s “Patient Information” (undated), the Patient Information indicated a start of care date of 8/6/2024 with a primary diagnosis of “Other Intervertebral Disc Degeneration (an age-related disorder due to the loss of disk height, increased disk bulging and subsequent pressure on nerve roots that lead to chronic back pain) Lumbar Region (Lower back region of backbone)”. During a review of Patient 6’s “Home Health Certification and Plan of Care (written document developed for each individual by the agency using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual)”, with a certification period from 8/6/2024 to 10/4/2024, the documentation indicated the following for Patient 6: - An order for skilled nurse (SN) visits of twice a week for two weeks, then once a week for seven weeks. - Patient 6 was a “homebound status, leaving home requires a considerable and taxing effort for the patient. Specify: Patient is confined because of illness, impaired mobility, prone to fall, unsteady gait, uncontrolled blood pressure (the force against blood vessel walls as the heart pumps blood), using of assistive devices, daily pain, taxing efforts to leave home unassisted.” - Discharge plans included “Discharge when medical condition is stable and patient is no longer in need of skilled services, discharge to care of physician, discharge when caregiver willing and able to manage all aspects of patient’s care and discharge when goal is met.” During a review of Patient 6’s Outcome and Assessment Information Set, (OASIS, is a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients) Discharge,” dated 8/10/2024, the “OASIS Discharge” indicated the Director of Patient Care Services (DPCS) conducted the assessment for Patient 6, but did not sign nor date the assessment. During a concurrent observation, interview, and review of the HHA Patient 6’s folder (patient information, medication list, and services being provided) on 8/21/2024 at 11:12 a.m. with Patient 6. During a visit to Patient 6’s home, translator was used to communicate with Patient 6 in her native language in Armenian. Patient 6 stated, she was discharged from HHA 3 on 7/27/2024. Patient 6 stated she did not know she was admitted to HHA 2 and did not know about HHA 2. Patient 6 stated, since she was discharged from HHA 3 on 7/27/2024, no nurse visited her from any HHA. Patient 6 presented HHA 3 folder and did not have any documents from HHA 2. The survey team attempted to interview DPCS on 8/21/2024, at 12:40 p.m., the DPCS was not available and was on vacation. The agency had no DPCS designee since June 2024. During a concurrent interview and record review on 8/22/2024, at 12:30 p.m., with the Administrator (ADM) and Office Staff 2 (OS 2), Patient 6’s “OASIS – Discharge,” dated 8/10/2024 was reviewed. The “OASIS - Discharge indicated, the documentation was not complete, and the DPCS did not sign and has no date in the documentation for Patient 6. The ADM and OS 2 stated that Patient 6’s “OASIS – Discharge” assessment for was incomplete and was not done, and the DPCS did not sign and has no date of the document. The ADM stated she did not know what happened to Patient 6, and she was confused to answer the question. The ADM stated the DPCS would come tomorrow and would be able to answer the questions. During an interview on 8/23/2024 at 11:47 a.m. with the ADM, the ADM stated, the DPCS was not answering her telephone calls and she went on a two-week vacation since last week. The ADM stated, she sent her Administrator Assistant (AA) to the DPCS’s residence, but no one was there. The ADM stated, she needed to travel out of the country to attend to a family emergency. During an attempted review of the facility’s policies and procedures (P&Ps), the HHA was unable to provide P&Ps related to Comprehensive Assessments and Discharge Process.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation on Organization and Administration of Services was met as follows: 1. Ensure a Director of Patient Care Services (DPCS) or a Director of Patient Care Services Designee (DD) was available during all operating hours to maintain a smooth functioning of the agency and maintain accurate and complete patient health records for two of seven sampled patients (Patient 1 and Patient 6). (Refer to G942). 2. Ensure the Administrator (ADM) performed her responsibilities to oversee and manage day-to-day operations of the agency, which included maintaining compliance with the federal regulations. (Refer to G942). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes for each patient. .

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure a governing body assume full responsibility for the operations of the HHA, has an organizational structure with clear lines of authority, and the HHA was operating within all legal bounds by failing to: 1. Ensure a Director of Patient Care Services (DPCS) or a Director of Patient Care Services Designee (DD) was available during all operating hours to maintain a smooth functioning of the agency and maintain accurate and complete patient health records for two of seven sampled patients (Patient 1 and Patient 6). 2. Ensure a Director of Patient Care Services (DPCS) or a Director of Patient Care Services Designee (DD) was available during all operating hours to ensure Patient 1 and Patient 6 discharge was organized and safe. 3. Ensure the Administrator (ADM) performed her responsibilities to oversee and manage day-to-day operations of the agency, which included maintaining compliance with the federal regulations. These deficient practices had the potential to result in disruption of patient care and services and in Patient 1 and Patient 6 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:25 p.m., the Department called a fourth IJ in the presence of the AD related to the HHA’s failure to ensure the Director of Patient Care Services (DPCSD) and the Administrator (ADM), acting as the governing body, assumed full responsibility for the day-to-day operation of the HHA and provision of care for two of seven sampled patients (Patient 1 and Patient 6). As a result, the noncompliance had the potential to result in disruption of patient care and services and in Patient 1 and Patient 6 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:32 p.m., the HHA did not provide an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely), and the AD stated the HHA would be closed (for business) and will no longer be opened. The survey team was unable to complete the survey tasks. On 8/23/2024 at 5:35 p.m., the HHA did not submit an IJ removal plan. The survey team left with the IJ not removed. a. A review of Patient 1’s Patient Information indicated that Patient 1 was admitted to the HHA on 4/9/2024 with a primary diagnosis of primary generalized osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time, causing bones to rub together). A review of Patient 1’s Home Health Certification and Plan of Care (a document outlining the timeframe a patient will be receiving home health services, the types of home health services and items needed by the patient, the frequency of the services, and the predicted outcomes of treatment/services) for the certification period of 6/8/2024 to 8/6/2024, indicated that Patient 1 was receiving Skilled Nurse (SN) service once a week for one week, twice a week for the following two weeks, and once a week for the remaining six weeks. The Home Health Certification and Plan of Care indicated that Physical Therapist would evaluate patient to determine the frequency needed. A review of Patient 1’s Physician’s Order, dated 6/13/2024, indicated the frequency for physical therapy was once a week for eight weeks. A review of Patient 1’s Discharge Summary, dated 7/26/2024, indicated that Patient 1 received skilled nursing and physical therapy services from the HHA. The Discharge Summary indicated the reason for discharge was Patient 1’s goals were met, and condition improved. The Discharge Summary also indicated that discharge instructions were provided to Patient 1 and all services notified and discontinued. During a joint home visit to Patient 1’s residence on 8/21/2024 at 12:30 p.m. with Registered Nurse 2 (RN 2), Patient 1 was observed alert, oriented, and ambulatory (able to walk about, not bedridden). On 8/21/2024, at 12:43 p.m., during an interview with Patient 1 in her native language (Russian), Patient 1 stated she had been a patient of HHA 2 for more than three years. Patient 1 stated that she had been visited by a nurse and a physical therapist from HHA 2 once a week. Patient 1 stated the nurse would check her temperature, blood pressure, and pain level during the visits, and help her with medication refills. Patient 1 stated she had been receiving physical therapy for her shoulders. According to Patient 1, she had arthritis (redness and swelling/inflammation in a joint) in both of her shoulders, causing pain and stiffness. When Patient 1 was asked about the last time she was seen by the nurse and the physical therapist, Patient 1 stated that she was seen by the physical therapist the day before (8/20/2024), and she was last seen by the nurse the previous week. During the same interview, Patient 1 was asked if she was aware that she had been discharged from HHA 2 on 7/26/2024. Patient 2 stated she had not been discharged because she was just visited by the physical therapist the previous day (8/21/2024), and the physical therapist did not say she would be discharged. Patient 2 stated her nurse did not inform her she would be discharged when she was seen last week. During the home visit, Patient 1’s home folder from HHA 2 was reviewed. Inside the home folder, the surveyor observed a copy of Patient Discharge Instructions/Notification, dated 7/26/2024. The Patient Discharge Instructions/Notification form had Patient 1’s name and Patient 1’s signature. The form also had a signature on the Professional Signature line, and Registered Nurse 1’s (RN 1) name next to the signature. The section for Special Instructions and Significant Telephone Numbers were blank. During an interview with Patient 1 in her native language (Russian) on 8/21/2023 at 1 p.m., Patient 1 confirmed that it was her signature on the Patient Discharge Instructions/Notification form. Patient 1 stated she did not understand what was written on the Patient Discharge Instructions/Notification form, because it was written in English. Patient 1 stated she signed the form because the nurse asked her to. Patient 1 stated she did not remember when she signed it. A review of Patient 1’s Skilled Nursing Visit notes, completed by Licensed Vocational Nurse 1 (LVN 1), dated 7/22/2024, indicated that discharge instructions were given. A request was made to speak with LVN 1 on 8/23/2024 at 1:58 p.m. LVN 1 did not respond to the request. During an interview with the Administrator (ADM) on 8/23/2024 at 11:47 a.m., the ADM stated the Director of Patient Care Services (DPCS) was not answering her telephone calls. Per ADM, the DPCS had been on a two-week vacation since last week. The ADM stated she sent her Administrator Designee (AD) to the DPCS’ residence, but no one answered the door. The ADM also stated that her office had been attempting to contact RN 1, who is the DPCS Designee, but RN 1 was not answering her phone. The ADM stated she had another DPCS Designee, who was going to come to the HHA’s office. On 8/23/2024, at approximately 1:30 p.m., RN 3 arrived at HHA’s office. During an interview with RN 3 on 8/23/2024, at 2 p.m., RN 3 stated she had never heard of HHA 2. RN 3 stated she helped the ADM with HHA 4 eleven years ago, when the ADM asked RN 3 for her assistance to start her home health business. RN 3 stated she helped the ADM filing the application for HHA 4’s license. RN 3 stated she only worked for the ADM as a consultant, and that she was never a DPCS Designee. RN 3 stated the last time she consulted HHA 4 was more than a year ago, when she provided an in-service on OASIS (Outcome and Assessment Information Set, a comprehensive assessment designed to collect information on nearly 100 items related to a home care recipient’s demographic information, clinical status, functional status, and service needs). Per RN 3, she came to HHA 2’s office today because the ADM called her and asked her to help. During a telephone interview with RN 1 on 8/23/2024 at 2:10 p.m., RN 1 stated she had resigned from HHA 2 in June 2024. RN 1 she used to work as a visiting nurse for HHA 2. RN 1 stated she had informed the administrator verbally in June 2024 that she could no longer work. RN 1 stated she never worked as a DPCS Designee for HHA 2. A review of HHA 2’s undated policy, titled “Discharge Planning, Transfer, and Continuing Care Needs,” indicated the following: - The staff member should prepare the patient for discharge by instructing the patient/caregiver to perform necessary care or should work making alternative plans for continuing care when further health care is needed. - Patients are informed prior to discharge of plans for discharge and the reason for discharge. The HHA did not provide a policy on governing body as requested by the survey team on 8/22/2024. b. A review of Patient 6’s untitled admission record, indicated a start of care date of 8/6/2024 with a primary diagnosis of Other Intervertebral Disc Degeneration (an age-related disorder due to the loss of disk height, increased disk bulging and subsequent pressure on nerve roots that lead to chronic back pain) Lumbar Region (Lower back region of backbone). During a review of Patient 6’s “Home Health Certification and Plan of Care (written document developed for each individual by the agency using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual)”, with a certification period from 8/6/2024 to 10/4/2024, indicated an order of skilled nurse (SN) visits of twice a week for two (2) weeks then once a week for seven (7) weeks. It further indicated that Patient 6 is a “homebound status, leaving home requires a considerable and taxing effort for the patient. Specify: Patient is confined because of illness, impaired mobility, prone to fall, unsteady gait, uncontrolled blood pressure (the force against blood vessel walls as the heart pumps blood), using of assistive devices, daily pain, taxing efforts to leave home unassisted”, with a discharge plans “Discharge when medical condition is stable and patient is no longer in need of skilled services, discharge to care of physician, discharge when caregiver willing and able to manage all aspects of patient’s care and discharge when goal is met.” During a review of Patient 6’s “OASIS (Outcome and Assessment Information Set, is a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients) Discharge”, dated 8/10/2024, indicated the name of the Director of Patient Care Services (DPCS) that conducted the assessment but did not sign and date it. During a home visit with Patient 6 on 8/21/2024 at 11:12 a.m., Patient 6 stated in her native language that she does not know that she does not know about Home Health Agency 2 (HHA2). Patient 6 stated that she used to be a patient of Home Health Agency 3 (HHA 3) but she was discharged on 7/27/2024. Patient 6 stated that there was no nurse that visited her from any other agency than from the HHA3 but it was since 7/27/2024 when a HHA3 nurse visited her. During observation, Patient 6 presented her HHA3 folder, she stated that she has no other documents to present that she was admitted and discharged from HHA2. Patient 6 stated that there were no nurses from HHA2 that came to check or visit her, she stated she does not hear or know HHA2’s name. Patient 6 stated HHA2 nurse did not come to assess or provide any discharge instructions to her. On 8/21/2024, at 12:40 p.m., a request was made from the Administrator (ADM) to speak with the DPCS but was unsuccessful. On 8/21/2024, at 12: 47 p.m., a telephone call was made to LVN 1 but was unsuccessful. During a concurrent interview and record review on 8/22/2024, at 12:58 p.m. with the Administrator (ADM) and Office Staff 2 (OS2), Patient 6’s electronic medical records, The OS2 and ADM were unable to locate any documented evidence that discharge instructions or notifications were provided to Patient 6. During an interview with the Administrator (ADM) on 8/23/2024 at 11:47 a.m., the ADM stated the Director of Patient Care Services (DPCS) was not answering her telephone calls. Per ADM, the DPCS had been on a two-week vacation since last week. The ADM stated she sent her Administrator Designee (AD) to the DPCS’ residence, but no one answered the door. The ADM also stated that her office had been attempting to contact RN 1, who is the DPCS Designee, but RN 1 was not answering her phone. The ADM stated she had another DPCS Designee, who was going to come to the HHA’s office.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA 2, [HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence]) failed to ensure the Condition of Participation regarding Clinical Records was met when: 1. The HHA 2 failed to ensure the clinical records for comprehensive assessments, skilled nurse visits, and discharge assessments were completed for one of seven sampled patients (Patient 6). (Refer to G 1012) 2. The HHA 2 failed to ensure that clinical records for 103 of 103 discharged patients were safeguarded against loss or unauthorized use. (Refer to G 1028) 3. The HHA 2 failed to complete a discharge summary (a narrative document for communicating clinical information about what happened to the patient), which will be sent to the primary care practitioner or other health care professional and who will be responsible for providing care and services to the patient after discharge from the HHA 2 within five business days of patient’s discharge for seven out of 103 discharged patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). (Refer to G 1022) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records were safeguarded against loss or unauthorized access and were inclusive of all assessments, nurse visit documentation, and discharge documentation.

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 observation, interview, and record review, the Home Health Agency (HHA 2 [HHA, an organization that delivers skilled nursing and other therapeutic services to a patient's personal residence, rather than in a more traditional healthcare facility setting] failed to ensure any amendments, corrections or late entries within a patient’s electronic medical record clearly identified the original content, the modified content, and the applicable dates and authorship of each record for one of seven selected patients (Patient 6). This failure had the potential to result in inaccurate patient information or assessments being entered in the patient’s clinical record, which could have negatively affected the patient’s quality of care received and their overall well-being. On 8/23/2024 at 4:05 p.m., the Department called a second IJ in the presence of the agency’s Office Staff 1 and Office Staff 2, related to the HHA's failure to ensure the clinical records for comprehensive assessment, skilled nurse visits, and discharge assessment were complete and consistent for one of seven sampled patients (Patient 6). The Administrator was not available when calling an IJ. As a result, the noncompliance resulted in the HHA providing care without assessing and identifying the needs of Patient 6, which was likely to cause unidentified needs not being met, which could have caused serious injury and could have led to hospitalization and death. On 8/23/2024 at 5:32 p.m., the HHA did not provide an IJ removal plan, and the AD stated the HHA would be closed (for business) and would no longer be opened. The survey team was unable to complete the survey tasks. On 8/23/2024 at 5:35 p.m., the HHA did not submit an IJ removal plan. The survey team left with the IJ not removed. . Findings: During a review of Patient 6’s “Patient Information (contains a patient’s identification, demographic, and medical information),” (undated), the “Patient Information” indicated, Patient 6 was admitted to HHA 2 on 8/6/2024 with a primary diagnosis of “Other Intervertebral Disc Degeneration (an age-related disorder due to the loss of disk height, increased disk bulging and subsequent pressure on nerve roots that lead to chronic back pain) Lumbar Region (Lower back region of backbone).” During a review of Patient 6’s “Home Health Certification and Plan of Care (written document developed for each individual by the agency using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual),” with a certification period from 8/6/2024 to 10/4/2024, the documentation indicated the following for Patient 6: - An order for skilled nurse (SN) visits of twice a week for two weeks, then once a week for seven weeks. - Patient 6 was “homebound status, leaving home requires a considerable and taxing effort for the patient. Specify: Patient is confined because of illness, impaired mobility, prone to fall, unsteady gait, uncontrolled blood pressure (the force against blood vessel walls as the heart pumps blood), using of assistive devices, daily pain, taxing efforts to leave home unassisted.” - Discharge plans included “Discharge when medical condition is stable and patient is no longer in need of skilled services, discharge to care of physician, discharge when caregiver willing and able to manage all aspects of patient’s care and discharge when goal is met.” During a review of Patient 6’s “OASIS (Outcome and Assessment Information Set, is a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients) – E Start of Care,” dated 8/6/2024, the “OASIS – E Start of Care” indicated, Registered Nurse 1 (RN 1) conducted the assessment for Patient 6, but did not sign nor date the assessment. During a review of Patient 6’s “OASIS Discharge,” dated 8/10/2024, the “OASIS Discharge” indicated, the Director of Patient Care Services (DPCS) conducted the assessment for Patient 6, but did not sign nor date the assessment. During a review of Patient 6’s “LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse) – Skilled Nursing Visit,” dated 8/13/2024 and 8/16/2024, the documentation indicated, Licensed Vocational Nurse 1 (LVN 1) conducted the visits, completed vital signs, and completed skilled observations/assessments/skilled intervention/coordination plan for Patient 6, and did sign and date the documentation for 8/13/2024 and 8/16/2024. During a concurrent observation, interview, and record review on 8/21/2024 at 11:12 a.m., with Patient 6 during a visit to her home, a translator was used to communicate with Patient 6 in her native language of Armenian, and Patient 6’s of the HHA 2 folder (patient information, medication list, and services being provided) was reviewed. Patient 6 stated, she was discharged from HHA 3 on 7/27/2024. Patient 6 stated, she did not know she was admitted to HHA 2 and did not know about HHA 2. Patient 6 stated, since she was discharged from HHA 3 on 7/27/2024, no nurse visited her from any HHA after her discharge date. Patient 6 presented her HHA 3 folder and did not have any documents from HHA 2. During a concurrent interview and record review on 8/22/2024 at 12:20 p.m. with the Administrator (ADM) and Office Staff 2 (OS 2), Patient 6’s “OASIS – E Start of Care,” dated 8/6/2024 was reviewed. The “OASIS – E Start of Care” indicated, the documentation was not complete, and RN 1 did not sign nor date the documentation for Patient 6. The ADM and OS 2 confirmed that RN 1 did not sign nor date the “OASIS – E Start of Care” for Patient 6. The ADM stated, she did not know what happened to Patient 6, and she was confused to answer the question. The ADM further stated, the DPCS would come the following day and would be able to answer the questions. During a concurrent interview and record review on 8/22/2024 at 12:30 p.m. with the ADM and OS 2, Patient 6’s “OASIS Discharge,” dated 8/10/2024 was reviewed. The “OASIS Discharge” indicated, the documentation was not complete, and the DPCS did not sign nor date the documentation for Patient 6. The ADM and OS 2 stated and confirmed, the “OASIS Discharge” assessment for Patient 6 was not complete and not done yet, and the DPCS did not sign nor date the document. The ADM stated, she did not know what happened to Patient 6, and she was confused to answer the question. The ADM further stated, the DPCS would be able to answer the questions the following day. During a concurrent interview and record review on 8/22/2024 at 12:47 p.m. with the ADM and OS 2, Patient 6’s “LPN/LVN – Skilled Nursing Visit,” dated 8/13/2024 and 8/16/2024, were reviewed. The “LPN/LVN Skilled Nursing Visits” indicated, these visits were completed on 8/13/2024 and 8/16/2024, and LVN 1 signed and dated the documentation. The ADM and OS 2 stated and confirmed, the Skilled Nursing Visits for Patient 6 were done after Patient 6 was discharged on 8/6/2024. The ADM stated, she did not know what happened to Patient 6, and she was confused to answer the question. The ADM stated, the DPCS would be able to answer the questions the following day. Upon further review of Patient 6’s electronic medical records with the ADM and OS 2, there was no other documented evidence to explain the additional visits received by Patient 6 from LVN 1, after Patient 6 was discharged on 8/6/2024. During an interview on 8/23/2024 at 11:47 a.m. with the ADM, the ADM stated, the DPCS was not answering her telephone calls and she went on a two-week vacation since last week. The ADM stated, she sent her Administrator Assistant (AA) to the DPCS’s residence, but no one was there. The ADM further stated, she needed to travel out of the country to attend to a family emergency. During an attempted review of the facility’s policies and procedures (P&Ps), the Agency was unable to provide P&Ps related to clinical records, as requested by the survey team.

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, observation, and record review, the Home Health Agency (HHA 2 [HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence]) failed to complete a discharge summary (a narrative document for communicating clinical information about what happened to the patient), which will be sent to the primary care practitioner or other health care professional and who will be responsible for providing care and services to the patient after discharge from the HHA 2 within five business days of discharge for seven out of 103 discharged patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This deficient practice had the potential to cause the lack of continuity of care which might affect patients’ overall well-being and and health outcomes. Findings: a. During a review of Patient 1’s "Patient Information (contains a patient’s identification, demographic, and medical information)," (undated), the "Patient Information" indicated Patient 1 was admitted to the HHA 2 on 4/9/2024 with a primary diagnosis of primary generalized osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time, causing bones to rub together). During a review of Patient 1’s "Discharge Summary", dated 7/26/2024, the "Discharge Summary" indicated Patient 1 received skilled nursing and physical therapy services from the HHA 2. The "Discharge Summary" indicated the reason for discharge was Patient 1’s goals were met, and condition improved. The "Discharge Summary" also indicated that discharge instructions were provided to Patient 1 and all services notified and discontinued. During a joint home visit to Patient 1’s residence on 8/21/2024 at 12:30 p.m. with Registered Nurse 2 (RN 2), Patient 1 was observed alert, oriented, and ambulatory (able to walk, not bedridden). During the home visit on 8/21/2023 at 1 p.m., Patient 1’s home folder from HHA 2 was reviewed. Inside the home folder, observed a copy of "Patient Discharge Instructions/Notification", dated 7/26/2024. The "Patient Discharge Instructions/Notification" form had Patient 1’s name and Patient 1’s signature. The "Patient Discharge Instructions/Notification" form was signed by the Registered Nurse 1’s (RN 1) on the Professional Signature line. The "Special Instructions and Significant Telephone Numbers" section was blank. During an interview with Patient 1 in her native language (Russian) on 8/21/2023 at 1 p.m., Patient 1 confirmed that it was her signature on the "Patient Discharge Instructions/Notification" form. Patient 1 stated she did not understand what was written on the "Patient Discharge Instructions/Notification" form, because it was written in English. Patient 1 stated she signed the form because the nurse asked her to sign. Patient 1 stated she did not remember when she signed the form. During a review of Patient 1’s "Discharge Summary", dated 7/26/2024, the "Discharge Summary" indicated Patient 1’s current status as needing assistance. The "Discharge Summary" indicated Patient 1 was advised of appropriate follow-up and Patient 1 verbalized understanding of need of medical follow-up, however, there was no narrative in the "Discharge Summary" regarding what type of medical follow-up needed Patient 1, with which physician Patient 1 needed to follow-up, and/or which physician would be responsible for Patient 1’s health care needs after she was discharged from HHA 2. b. During a review of Patient 2’s "Patient Information" (undated), the "Patient Information" indicated Patient 2 was admitted to the HHA 2 on 6/7/2024 with a primary diagnosis of hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone and the deficiency of this hormone can disrupt the heart rate, body temperature, and all aspects of metabolism). During a review of Patient 2’s "Discharge Summary", dated 7/30/2024, the "Discharge Summary" indicated Patient 2 received skilled nursing and physical therapy services from HHA 2. The "Discharge Summary" indicated the reason for discharge was Patient 2’s goals were met and condition improved. The "Discharge Summary" also indicated that discharge instructions were provided to Patient 2 and all services notified and discontinued. During a review of Patient 2’s "Discharge Summary", dated 7/30/2024, the "Discharge Summary" indicated Patient 2’s current status as needing assistance. The "Discharge Summary" indicated Patient 2 was advised of appropriate follow-up and Patient 2 verbalized understanding of need of medical follow-up, however there was no narrative in the "Discharge Summary" regarding what type of medical follow-up Patient 2 needed, with which physician Patient 2 needed to follow-up, and/or which physician would be responsible for Patient 2’s health care needs after he was discharged from HHA 2. During a telephone interview with Patient 2’s mother on 8/21/2024 at 3:35 p.m., in her native language (Armenian), Patient 2’s mother stated Patient 2 was not available for an interview. Patient 2’s mother stated Patient 2 was a patient of HHA 2. Connection with the interpreter was lost during the interview and when attempted to call the patient again, the call was not answered. During a telephone interview with Patient 2’s mother on 8/23/2024 at 10 a.m., in her native language (Armenian), Patient 2’s mother stated Patient 2 was not available for an interview. Patient 2’s mother stated that she did not want to answer any questions from the survey team. c. During a review of Patient 3’s "Patient Information" (undated), the "Patient Information" indicated Patient 3 was admitted to the HHA 2 on 5/3/2024 with a primary diagnosis of other polyosteoarthritis (arthritis that affects five or more joints at the same time). The HHA 2 did not provide Patient 3’s "Skilled Nursing Notes" and "Discharge Summary" as requested by the survey team on 8/23/2024. Telephone calls made to Patient 3 on 8/21/2024 at 4:02 p.m. and on 8/22/2024 at 9:44 a.m. The calls were unanswered and unreturned. d. During a review of Patient 4’s "Patient Information" (undated), the "Patient Information" indicated Patient 4 was admitted to the HHA 2 on 5/2/2024 with a primary diagnosis of other polyosteoarthritis. During a review of Patient 4’s "Discharge Summary", dated 7/6/2024, the "Discharge Summary" indicated Patient 4 received skilled nursing and physical therapy services from HHA 2. The "Discharge Summary" indicated the reason for discharge was Patient 4’s goals were met and condition improved. The "Discharge Summary" also indicated that discharge instructions were provided to Patient 4 and all services notified and discontinued. During a review of Patient 4’s "Discharge Summary", dated 7/6/2024, the "Discharge Summary" indicated Patient 4’s current status as needing assistance. The Discharge Summary indicated Patient 4 was advised of appropriate follow-up and Patient 1 verbalized understanding of need of medical follow-up, however, there was no narrative in the "Discharge Summary" regarding the type of medical follow-up needed by Patient 4, with which physician Patient 4 needed to follow-up, and/or which physician would be responsible for Patient 4’s health care needs after she was discharged from HHA 2. Telephone calls made to Patient 4 on 8/21/2024 at 3:50 p.m. and on 8/22/2024 at 9:43 a.m. Calls were unanswered and unreturned. During an interview on 8/20/2024 at 2:50 p.m. with the ADM, the ADM stated HHA 2 did not have any active patients at the time of the interview and visit. The ADM stated that she was the administrator for four HHAs owned by her mother: HHA 1, HHA 2, HHA 3, and HHA 4. According to the ADM, her mother was currently sick and was undergoing treatment in overseas. The ADM stated she decided to discharge all patients of HHA 1, HHA 2, HHA 3, and HHA 4, so the ADM could focus on taking care of her mother. The ADM stated none of the patients were referred to another HHA for their continuing health care needs. The ADM did not provide an answer to the question on how HHA could ensure the discharged patients’ home care needs would be met after the discharge. During an interview with the ADM on 8/23/2024 at 12 p.m., the ADM stated the survey team could ask all clinical related questions to the Registered Nurse 1 (RN 1), who was the HHA’s Director of Patient Care Services Designee (DPCSD). The ADM also stated that RN 1 was unable to come to the HHA’s office as requested by the survey team, but RN 3, who was also a DPCSD, was going to come to the HHA’s office and answer the survey team’s clinical questions. On 8/23/2024, at approximately 1:30 p.m., RN 3 arrived at HHA’s office. During an interview with RN 3 on 8/23/2024, at 2 p.m., RN 3 stated she had never heard of HHA 2. RN 3 stated she helped the ADM with HHA 4 eleven years ago, when the ADM asked RN 3 for her assistance to start her home health business. RN 3 stated she helped the ADM filing the application for HHA 4’s license. RN 3 stated she only worked for the ADM as a consultant, and she was never a DPCS Designee. RN 3 stated the last time she consulted HHA 4 was more than a year ago, when she provided an in-service on OASIS (Outcome and Assessment Information Set, a comprehensive assessment designed to collect information on nearly 100 items related to a home care recipient’s demographic information, clinical status, functional status, and service needs). Per RN 3, she came to HHA 2’s office today because the ADM called her and asked her to help. During a telephone interview with RN 1 on 8/23/2024 at 2:10 p.m., RN 1 stated she had resigned from HHA 2 in June 2024. RN 1 stated she used to work as a visiting nurse for HHA 2. RN 1 stated she had informed the administrator verbally in June 2024 that she could no longer work. RN 1 stated she never worked as a DPCS Designee for HHA 2. A review of HHA 2’s undated policy and procedure (P&P), titled “Discharge Planning, Transfer, and Continuing Care Needs,” indicated the following: The staff member should prepare the patient for discharge by instructing the patient/caregiver to perform necessary care or should work making alternative plans for continuing care when further health care is needed Patients are informed prior to discharge of plans for discharge and the reason for discharge. The agency will work with the physician and patient/caregiver in arranging continuing care of the patient. e. During a review of Patient 5’s “Patient Information,” (undated), the “Patient Information” indicated, Patient 5 was admitted to HHA 2 on 5/9/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing).” During a review of Patient 5’s "Discharge Summary", dated 7/29/2024, the "Discharge Summary" indicated Patient 1 received skilled nursing and physical therapy services from HHA 2. The "Discharge Summary" indicated the reason for discharge was Patient 5’s goals were met and condition improved. The "Discharge Summary" also indicated that discharge instructions were provided to Patient 5 and all services notified and discontinued. During a joint home visit to Patient 5’s residence on 8/21/2024 at 10:00 a.m. with Registered Nurse 2 (RN 2), Patient 5 was observed alert, oriented, and ambulatory (able to walk, not bedridden). During an interview with Patient 5 in his native language (Armenian) on 8/21/2023 at 10:15 a.m., Patient 5 stated he was discharged from HHA 2 since 7/29/2024. Patient 5 stated he signed some discharge instructions and documents, but stated he cannot find it and it might be placed somewhere in his residence. Patient 5 stated he understood the nurse’s explanation regarding his discharge. During a review of Patient 5’s "Discharge Summary", dated 7/29/2024, the "Discharge Summary" indicated Patient 5’s current status as needing assistance. The "Discharge Summary" indicated Patient 5 was advised of appropriate follow-up and Patient 5 verbalized understanding of need of medical follow-up, however, there was no narrative in the "Discharge Summary" regarding the type of medical follow-up needed Patient 5, with which physician Patient 5 needed to follow-up, and/or which physician would be responsible for Patient 5’s health care needs after she was discharged from HHA 2. f. During a review of Patient 6’s “Patient Information,” (undated), the “Patient Information” indicated, Patient 6 was admitted to HHA 2 on 8/6/2024 with a primary diagnosis of "Other intervertebral disc degeneration (an age-related disorder due to the loss of disk height, increased disk bulging and subsequent pressure on nerve roots that lead to chronic back pain) lumbar region (lower back region of backbone).” During a review of Patient 6’s “Home Health Certification and Plan of Care” with a certification period from 8/6/2024 to 10/4/2024, the “Home Health Certification and Plan of Care” indicated the following for Patient 6: - Skilled nurse (SN) visits of twice a week for two weeks, then once a week for seven weeks. -Patient 6 was “homebound status, leaving home requires a considerable and taxing effort for the patient. Specify: Patient is confined because of illness, impaired mobility, prone to fall, unsteady gait, uncontrolled blood pressure, using of assistive devices, daily pain, taxing efforts to leave home unassisted.” - Discharge plans included “Discharge when medical condition is stable and patient is no longer in need of skilled services, discharge to care of physician, discharge when caregiver willing and able to manage all aspects of patient’s care and discharge when goal is met.” During a review of Patient 6’s “OASIS Discharge,” dated 8/10/2024, the “OASIS Discharge” indicated, the Director of Patient Care Services (DPCS) conducted the assessment of Patient 6, but did not sign nor date the assessment. During a concurrent observation, interview, and record review on 8/21/2024 at 11:12 a.m., with Patient 6 in her residence, a translator was used to communicate with Patient 6 in her native language in Armenian. During home visit, Patient 6’s HHA 2's folder (patient information, medication list, and services being provided) was reviewed. Patient 6 stated, she was discharged from HHA 3 on 7/27/2024. Patient 6 stated, she did not know she was admitted to HHA 2 and did not know about HHA 2. Patient 6 stated, since she was discharged from HHA 3 on 7/27/2024, no nurse visited her from any HHA after her discharge date. Patient 6 presented her HHA 3 folder and did not have any documents from HHA 2. During a concurrent interview and record review on 8/22/2024 at 12:30 p.m. with the ADM and OS 2, Patient 6’s “OASIS Discharge,” dated 8/10/2024, was reviewed. The “OASIS Discharge” indicated, the documentation was not complete, and the DPCS did not sign nor date the documentation for Patient 6. The ADM and OS 2 stated and confirmed, the “OASIS Discharge” assessment for Patient 6 was not complete and not done, and the DPCS did not sign nor date the document. The ADM stated, she did not know what happened to Patient 6, and she was confused to answer the question. The ADM further stated, the DPCS would be able to answer the questions the following day. g. During a review of Patient 7’s “Patient Information,” (undated), the “Patient Information” indicated, Patient 7 was admitted to HHA 2 on 5/11/2024, with a current episode of 5/11/2024 to 5/31/2024 and a primary diagnosis of hypertensive heart disease (a disease which refers to heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition where the heart muscle becomes weak and unable to pump blood and oxygen around the body).” During a review of “HHA1’s (Home Health Agency 1) discharge patients list”, (undated), the “HHA1’s discharge patients list” indicated that Patient 7 also was admitted to HHA1 with Start of Care date of 5/5/2024 and current episode of 5/5/24 to 7/3/2024. During a telephone interview on 8/20/2024 at 2:09 p.m., with Patient 7, Patient 7 stated, she did not know she was admitted to HHA 2 and did not know about HHA 2. Patient 7 stated she does not remember that a nurse visited her from any HHA 2. Patient 7 stated since she remembered, she was a patient of HHA 1 but not HHA 2. During an interview on 8/20/2024 at 2:50 p.m. with the ADM, the ADM stated the HHA 2 did not have any active patients at the time of the interview and visit. The ADM stated that she was the administrator for four HHAs owned by her mother: HHA 1, HHA 2, HHA 3, and HHA 4. According to the ADM, her mother was currently sick and was undergoing treatment in overseas. The ADM stated she decided to discharge all patients of HHA 1, HHA 2, HHA 3, and HHA 4, so the ADM could focus on taking care of her mother. The ADM stated none of the patients were referred to another HHA for their continuing health care needs. The ADM did not provide an answer on how HHA 2 could ensure the discharged patients’ home care needs would be met after the discharge. The ADM stated that the survey team could ask all clinical related questions to Registered Nurse 1 (RN 1), who was the HHA’s Director of Patient Care Services Designee (DPCSD). The ADM also stated that RN 1 was unable to come to the HHA’s office as requested by the survey team, but RN 3, who was also a DPCSD, was going to come to the HHA’s office and answer the survey team’s clinical questions. On 8/20/2024, at 3:41 p.m., a call was made to RN 1 by the Office Staff 1. There was no answer to the call. A message was left to return the call. During an interview on 8/22/2024 at 2:47 p.m., with the ADM, requested ADM to provide the discharge physical charts which included the discharge dates, HHA plan of care (form that summarizes a person's health conditions and current treatments for their care), reason for admission to HHA 2, patient’s discharge condition, patient’s outcomes in meeting the goals in the plan of care, and patient and family post discharge instructions for three (3) discharged patients (Patient 5, Patient 6, and Patient 7). During an interview on 8/22/2024, at 4:30 p.m., with ADM, the ADM stated the discharge physical charts of patients Patient 5, Patient 6, and Patient 7 were in the storage unit. Informed the ADM to provide the discharged patients physical charts (Patient 5, Patient 6, and Patient 7) by 8/22/2024. During a concurrent interview and review of a Storage Unit receipt, dated 8/20/2024, with the Administrator Designee (AD), on 8/22/2024 at 4:38 p.m., the AD stated Office Staff 2 (OS 2) went to the storage unit where the physical charts of the three discharged patients (Patient 5, Patient 6 , and Patient 7) were located, but OS 2 was not able to bring them because the storage unit was closed. During an interview on 8/23/2024 at 11:30 a.m., with the ADM, another request was made to the ADM to provide physical charts of the three discharged patients (Patient 5, Patient 6, and Patient 7) for the review. During an interview on 8/23/2024 at 11:47 a.m. with the ADM, the ADM stated, the DPCS was not answering her telephone calls and she went on a two-week vacation since last week. The ADM stated, she sent her Administrator Assistant (AA) to the DPCS’s residence, but no one was there. The ADM further stated, she needed to travel out of the country to attend to a family emergency. During an interview on 8/23/2024, at 12:30 p.m., with OS 1, requested OS 1 to provide the physical charts of three discharged patients (Patient 5, Patient 6, and Patient 7) for the review. OS 1 stated she would remind the ADM of the request. On 8/23/2024 at 5:15 p.m., the HHA did not provide three discharged Patients (Patient 5, Patient 6, and Patient 7) physical charts as requested by the survey team. The discharge patient physical charts requested since 8/22/2024 and HHA 2 did not provide.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA 2 [HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence]) failed to ensure the safeguarding of clinical records against unauthorized access or loss for 103 out of 103 discharged patients. This failure had the potential to result in the discharged patients’ protected health information (PHI, any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) being accessed and/or misused by unauthorized personnel, in addition to the heightened risk of the clinical records content being lost. On 8/20/2024 at 4:40 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) related to the Home Health Agency (HHA) failure to safeguard clinical records of 103 of 103 discharged patients from unauthorized access. As a result, the noncompliance had the potential to result in an unauthorized access and use of patients’ protected health information (PHI, any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) and loss of clinical records. On 8/23/2024 at 5:32 p.m., the HHA did not provide an IJ removal plan, and the AD stated the HHA would be closed (for business) and would no longer be opened. The survey team was unable to complete the survey tasks. On 8/23/2024 at 5:35 p.m., the HHA did not submit an IJ removal plan. The survey team left with the IJ not removed. .. Findings: During an observation on 8/20/2024 at 11:00 a.m. in the HHA 2’s office, there were three file cabinets observed inside the office space. The three file cabinets observed were unlocked, and 62 patient folders containing the respective patients’ PHI were observed in the three cabinets. The entry door to the HHA 2’s office was unlocked and there were no staff members present at the time of the observation. During a concurrent observation and interview on 8/20/2024 at 11:20 a.m. with Office Staff 1 (OS 1) in the HHA 2’s office, OS 1 entered HHA 2’s office and stated, there was no one in HHA 2’s office because all the staff were in a different office. Prior to OS 1 entering HHA 2’s office, the office’s entry door was open and without any staff members present, and the survey team was able to enter the room without staff assistance or awareness. During an observation on 8/20/2024 at 11:30 a.m. in the shared conference room for HHA 2 and HHA 3, located between the suites occupied by HHA 2 and HHA 3, 42 discharged patients’ “Personal Information (contains a patient’s identification, demographic, and medical information)” documents) were found on the windowsill in the shared conference room. During an interview on 8/20/2024 at 12:50 p.m. with HHA 2’s ADM, the ADM confirmed that some of the discharged patient’s files were kept unsecured in HHA 2’s office, stored in the file cabinets without a lock. During an observation on 8/20/2024, at approximately 2:40 p.m., inside HHA 4’s office, the survey team observed HHA 2’s discharged patients’ clinical records located in a box, inside HHA 4’s office. HHA 2, HHA 3, and HHA 4 shared the same Administrator (ADM), and the three agencies were all located in the same building. HHA 2 and HHA 3 were located on the second floor, while HHA 4 was located on the first floor. During an interview on 8/20/2024 at 2:50 p.m. with HHA 2’s ADM, who was also the ADM of HHA 3, the ADM stated, HHA 2 and HHA 3 did not have any active patients at the time of the interview. The ADM stated, the patients’ clinical records were not safeguarded appropriately, because they were in the process of organizing and transferring the records into a storage. The ADM stated, HHA 2, HHA 3, and HHA 4 shared the same staff members. The ADM stated, “There are so many records because we have to keep them for seven years. It’s my mistake, I’m not organized.” The ADM further stated, it was not an acceptable practice to have the patients’ records unsecured and stored outside the agency’s office. During a review of the HHA 2’s policy and procedure (P&P) titled, “Patient Record: Protection and Retention,” (undated), the P&P indicated, every effort was made to protect records from being defaced, damaged, stolen, or lost. The P&P indicated that all information in the patient record was the private property of the organization and the respective patient, and was confidential. The P&P further indicated, all patient records shall be housed in physically-secure areas under the immediate control of designated staff, and access to areas housing patient records shall be limited to authorized personnel. During a review of the HHA 2’s P&P titled, “Patient’s Health Records Availability,” (undated), the P&P indicated, the agency shall protect patients from unnecessary intrusion into their private lives by safeguarding the health information entrusted to them.