Every finding on record at Quincy Home Medical Services

The following reflects the findings of the California Department of Public Health during a Federal Recertification survey conducted from 3/25/25 through 3/28/25. This Federal Recertification survey was a review of all federal regulations related to the operation of a Home Health agency and represents a full inspection of this agency. One anonymous Complaint (Number: 103954) was investigated concurrent to this survey. Admissions (unduplicated, for a 12-month period): 317 Current Census: 108 Sample Size: 10 Home Visits: 4 All Conditions of Participation were Met. One deficiency was written for Complaint 103954 a G - 942.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure seven of 10 sampled patients (Patient 1, 3, 4, 5, 7, 9, and Patient 10), was assessed by a Registered Nurse (RN) within 48-hours of their referral for home health care, or notify the physician when there was a delayed start of care (admission to agency). This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. Findings: During a review of the agency’s policy undated, titled, “Comprehensive Client Assessment,” indicated the initial assessment visit must be held either within 48 hours of referral or within 48 hours of the client’s return home, or the physician’s start of care date. The initial assessment bridges the gap between the first client encounter until a plan of care can be implemented. The purpose of this policy is to determine the appropriate care, treatment and services to meet client initial needs and his/her changing needs. During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 5/31/24 with diagnoses that included left femur fracture (broken bone of the thigh, the largest bone in the body), Atrial Fibrillation (irregular and fast heart rate), congestive heart failure (long term condition when your heart cannot pump enough blood for the body’s needs), diabetes (too much sugar in the blood), anxiety (a feeling of worry, nervousness or fear), and acute embolism (sudden obstruction of a blood vessel that travels in the bloodstream). During a review of Patient 1’s clinical record, a review of Patient 1’s visit documentation, it was noted that Patient 1 was referred to services on 5/27/24, but the start of care (SOC, initial comprehensive assessment) date was 5/31/24 (4 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent record review, and interview, on 3/25/25 at 2:30 pm, Administrative Assistant (AA) confirmed the SOC was not initiated within 48 hours for Patient 1. AA confirmed there was no documentation of a reason for the delay of the SOC, and no update sent to the physician to notify that services were delayed for Patient 1. During a review of Patient 4’s clinical record, Patient 1 was admitted to the home health agency on 2/25/25 with diagnoses that included respiratory failure with hypoxia (serious lung condition when there is not enough oxygen in the blood), pneumonia (a lung infection with inflammation and fluid making it hard to breathe), chronic kidney disease stage 3 (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), myocardial injury (heart attack with heart damage), depression (persistent sadness, or loss of interest with activities that affect daily life), pulmonary embolism (condition when a blood clot travels to the lungs and blocks one or more blood vessels), and transient ischemic attacks (mini strokes, when the oxygen supply is briefly blocked in the brain resolving in minutes). During a review of Patient 4’s clinical record, a review of Patient 4’s visit documentation, it was noted that Patient 4 was referred to services on 2/17/25, but the SOC date was 2/25/25 (8 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent interview and record review on 3/25/25 at 4:40 pm, the AA confirmed the SOC was not initiated within 48 hours for Patient 4. AA confirmed there was no documentation of a reason for the delay of the start of care, and no update was sent to the physician to notify that services were delayed for Patient 4. During a review of Patient 5’s clinical record, Patient 5 was admitted to the home health agency on 4/15/24 with diagnoses that included Peripheral Venous Deficiency (PVD, circulation problem with reduced blood flow to the arms and legs, causing pain, tingling, and numbness), venous stasis ulcers (non-pressure open sores that develop on the les or ankles from poor circulation), Urinary Tract Infection (UTI, infection of the urinary tract, most common human bacterial infection) high blood pressure, cellulitis (inflammation and infection of the skin and underlying tissues), and history of falling. During a review of Patient 5’s clinical record, a review of Patient 5’s visit documentation, it was noted that Patient 5 was referred to services on 4/8/24, but the SOC date was 4/15/24 (7 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent interview and record review on 3/27/25 at 1:30 pm, the AA and the Clinical Supervisor (CS) confirmed the SOC was not initiated within 48 hours for Patient 5. AA and CS confirmed there was no documentation of a reason for the delay of the start of care, and no update was sent to the physician to notify that services were delayed for Patient 5. During a review of Patient 9’s clinical record, Patient 9 was admitted to the home health agency on 1/20/25 with diagnoses that included subdural hematoma, chronic stage 3 kidney disease (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), hypothyroidism, depression (persistent sadness, or loss of interest with activities that affect daily life), anxiety (a feeling of worry, nervousness or fear), post-traumatic stress disorder (PTSD, mental health condition after experiencing trauma, leading to persistent distress, anxiety, nightmares, and flashbacks), macular degeneration (progressive, gradual loss of central vision), and repeated falls. During a review of Patient 9’s clinical record, a review of Patient 9’s visit documentation, it was noted that Patient 9 was referred to services on 1/15/25, but the SOC date was 1/20/25 (5 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent interview and record review on 3/27/25 at 3:55 pm, the AA and the CS confirmed the SOC was not initiated within 48 hours for Patient 9. AA and CS confirmed there was no documentation of a reason for the delay of the start of care, and no update was sent to the physician to notify that services were delayed for Patient 5. During a follow up interview on 3/28/25 at 10:00 am, the CS confirmed Patient 1, 3, 4, 5, 7, 9 and Patient 10 did not have a timely initiation of their SOC, and the physicians were not updated. CS stated, “We will work on a new process to make sure we meet this need moving forward, or we can ask the physician for a SOC date if indicated.” A review of Patient 3’s record indicated she had a referral date for admission for services from the agency on 5/6/24 and was admitted (start of care) on 5/13/24 (seven days later). Patient 3’s diagnoses included heart failure, high blood pressure, weakness and falls. A review of Patient 3’s physicians plan of care indicated orders for skilled nursing (SN) one time a week for 2 weeks (1W2) and 2 prn (as needed) for a change of condition. A “Delay in Initial Assessment …(Start of Care)” dated 5/8/24 notifying the physician of the delay of SOC was presented during the survey but failed to be signed by the physician. A review of Patient 7’s record indicated she had a referral date for admission for services from the agency on 3/6/25 and was admitted (start of care) on 3/11/25 (five days later). Patient 7’s diagnoses included a fractured left and right femur (thigh bone), history of falls, anemia, urinary tract infection and urinary incontinence. A review of Patient 7’s physicians plan of care indicated orders for SN one time a week for 8 weeks (1W8) and 4 prn visits for catheter and wound problems. During an interview and record review with the agency Clinical Supervisor (CS) on 3/27/25 at 4:10 pm she acknowledged Patient 7’s SOC was late stating it was not completed within 48 hours of the referral. A review of Patient 10’s record indicated she had a referral date for admission for services from the agency on 2/17/25 and was admitted (start of care) on 2/21/25 (four days later). Patient 10’s diagnoses included heart failure, hypertension and history of falling. A review of Patient 10’s physicians plan of care indicated orders for SN one time a week for 8 weeks (1W8) and 2 prn for change of condition. During an interview and record review with the agency CS on 3/28/25 at 9:34 am she acknowledged Patient 10’s SOC was late for nursing services.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to review and document all medications in the home for one out of four patients, (Patient 6) during the initial assessment and follow up home visits to include in the clinical record and for the physician to review for interactions. This failure had the potential to for unrecognized medication interactions to go unnoticed which could cause a negative clinical outcome. Findings: Patient 6's record was reviewed. Patient 6’s record indicated she was admitted (start of care) on 3/4/25, with diagnoses that included a fractured right lower leg, atrial fibrillation (irregular heart rate), long term use of anticoagulants (blood thinners) and a history of falling. The plan of care indicated the skilled nurse would visit one time a week for three weeks (1wk3), and 2 PRN (as needed) for change of condition. Physical Therapy (PT) would visit after their evaluation for 1 time a week for 5 weeks (1wk5). The POC indicated that SN would perform medication reconciliation to ensure safe medication management. The POC included that PT would assess functional status, structural barriers in the environment, rehabilitation potential, gait training, safety precautions and pain management. On 3/26/25 at 9:30 am, a visit to Patient 6’s home was conducted with Physical Therapist (PT) E. Patient 6 was observed sitting in her recliner with her legs elevated upon arrival. PT E was observed asking Patient 6 what her pain level was on her right foot and she replied “6” (a standardized pain scale of 1 to 10 with 0 being the least pain and 10 the highest). During the exercise session PT E frequently inquired about Patient 6’s pain level and instructed her to stop the exercises with increased pain. He never inquired what Patient 6 was taking for pain, and if it was effective. PT E only instructed on elevation and the application of ice. PT E never reconciled (observed) her medications she was taking in the home against her Medication Profile. After PT E left the home, concurrently at 11 am Patient 6’s medication bottles were reviewed with her while reviewing her Medication Profile. The Medication Profile indicated she was taking Acetaminophen (Tylenol) 650 milligrams (mg) one tablet every six hours as needed for pain. She stated the Tylenol was effective. Additionally, the Medication Profile indicated Patient 6 was receiving Potassium Chloride 10 milliequivalents (mEQ) one tablet daily by mouth. The bottle indicated Patient 6 was taking Potassium Chloride ER (extended release)10 mEq one tablet daily by mouth. There was also a bottle of Turmeric 500 mg per tablet with Patient 6’s medications. She stated at this time she takes two tablets every day. The Turmeric medication was not listed on her Medication Profile. Concurrently, at 10:40 am, Patient 6 also stated she takes Ultra Flora (a probiotic) supplement one tablet every day that was observed in Patient 6’s refrigerator. Both the Turmeric and the Ultra Flora medication were not documented on the Medication Profile. The Potassium Chloride failed to be documented on the profile as being extended release. A follow up interview, was conducted with PT E on 3/27/25 at 3:40 pm. He confirmed, that he did not ask Patient 6 what she was taking for pain, and did not look at her medication she was taking. He stated he usually focuses on ice, and elevation. A review, of the facility's undated “Medication Reconciliation and Documentation,” policy indicated the purpose was to ensure safe and correct administration of medication in patients’ homes. It directed that during the start of care or the resumption of care all bottles and containers including prescribed, over the counter medications, ointments and herbal supplements would be reviewed and evaluated for compliance to the physician's orders. The policy directs on each follow up visit nursing, and therapy would verify the patient is still following the previous Medication Profile list.

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 observation, interview, and record review, the agency failed to individualize all treatments, pertinent diagnoses interventions and goals as relevant to the plan of care for one out of 10 sampled patients, (Patient 5). This failure had the potential for unidentified problems, risk for hospitalization and negative clinical outcomes. Findings: A review, of the agency’s undated policy titled, “Plan of Care,” indicated that home care services are furnished under the supervision and direction of the client’s physician. The plan of care (POC) is based on a comprehensive assessment and information provided by the client/family and health team members. Planning for care is a dynamic process that addresses the care, treatment, and services to be provided. The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary, but at least every sixty days. The purpose of this policy is to provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs. Patient 5's record was reviewed. Patient 5 was admitted to the home health agency on 4/15/24, with diagnoses that included Peripheral Venous Deficiency (PVD, circulation problem with reduced blood flow to the arms and legs, causing pain, tingling, and numbness), venous stasis ulcers (non-pressure open sores that develop on the les or ankles from poor circulation), Urinary Tract Infection (UTI, infection of the urinary tract, most common human bacterial infection) high blood pressure, cellulitis (inflammation and infection of the skin and underlying tissues), and history of falling. During an interview, on 3/26/25 at 2:10 pm, Patient 5 stated, “I do not remember being in the hospital for 5 days with a UTI, I was out of it. I couldn’t believe how sick you can get; I don’t remember a lot. That was before my husband of 52 years passed away. He passed in August, just a few months ago, and I just had to put my dog down. It is just me now, but my neighbors do stop by and check in on me.” During a follow up interview, on 3/26/25 at 2:30 pm, Patient 5 stated, “I do not know how to prevent a UTI, and I did not know the nurse can collect a urine sample. Since I can no longer drive, that would be wonderful if I need to be checked. I never want to go back to the hospital for that again.” During a review of Patient 5’s record, a document dated 4/15/24, titled, “Plan of Care (POC),” indicated that Patient 5 had no orders, interventions, or goals for education, prevention, or knowing when to report signs and symptoms of a UTI. Despite a diagnosis of UTI being listed on her POC. During an interview, on 3/27/25 at 10 am, the Clinical Supervisor (CS) confirmed, that Patient 5’s POC was not specific, and individualized on the POC on admission for a history of a recent UTI, and not listed on any POCs following. During an interview, on 3/27/25 at 11 am, the Quality Assurance RN (QA) confirmed, that Patient 5 should have specific orders, interventions and goals for a UTI, especially since there was a history, and diagnosis to support these interventions.

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 observation, interview, and record review, the agency failed to identify and update the physician of a significant change in condition for three of 10 sampled patients (Patient 1, 3, and Patient 6) when: 1. Patient 1 had an elevated blood pressure (B/P) that was not immediately reported to the physician. 2. Patient 3 had an unwitnessed fall not reported to the physician. 3. Patient 6 had a new onset of edema (swelling) at the surgical site of the right ankle not reported to the physician. These failures had the potential for medical complications, hospitalizations, and did result in changes of conditions not reported to the physician which could cause a delay in treatment leading to negative clinical outcomes. Findings: During a review of the agency’s policy undated, titled, “Medical Supervision,” indicated physicians will be informed, at the same time their clients are admitted to the agency. The physician will be contacted when any of the following occurs: condition changes, expected response to treatment or medication changes, laboratory results are received, caregiver support or home environment changes, any change in client condition or agency services. In the event the primary physician is not available, the on-call physician for that clinic will be utilized. If the agency staff is unable to obtain orders from the on-call physician in a timely manner, the agency medical director will be utilized. During a review of the agency’s policy not dated, titled, “Coordination of Care,” indicated the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and communication with the physician. This policy also indicated Coordination of care means assuring that the client needs are continually assessed, addressed in the plan of care (POC), that care is delivered in a timely and effective manner, and goals are achieved.” During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 5/31/24 with diagnoses that included left femur fracture (broken bone of the thigh, the largest bone in the body), Atrial Fibrillation (irregular and fast heart rate), congestive heart failure (long term condition when your heart cannot pump enough blood for the body’s needs), high blood pressure, diabetes (too much sugar in the blood), anxiety (a feeling of worry, nervousness or fear), and acute embolism (sudden obstruction of a blood vessel that travels in the bloodstream). During a review of Patient 1’s clinical record, a document dated 5/31/25, titled, “Plan of Care (POC, physician orders that help nurses and other team members organize aspects of patient care with a timeline),” indicated on page 3 for skilled nursing to instruct on disease process for high (normal blood pressure for an adult is blood pressure (B/P) less than 130/80 millimeters of mercury (mmHg, a unit of measure) and expressed in two separate numbers, including medications, home management, monitoring B/P, and related nutrition, salt intake. During a review of Patient 1’s clinical record, a document dated 5/31/25, titled, “POC,” indicated on page 4 for high blood pressure goals: Patient will achieve a stable B/P. During a review of Patient 1’s clinical record, a document dated 6/4/24, titled, “Communication Note,” to the physician indicated Patient 1 had a B/P of 180/79 mmHg at the home visit on 6/4/24 with a history of hypertension (high blood pressure) and falls. This document for communication was signed on 6/12/24, 8 days after the elevated blood pressure was reported via fax. This document had a note added by the physician as follows: “Recheck blood pressure and monitor symptoms.” During an interview on 3/25/25 at 3:30 pm, the Quality Assurance Registered Nurse (QA) confirmed this B/P for Patient 1 was too high, and it should have been called to the physician for a timely response, and completed an additional nurse visit to follow up with Patient 1 to re-check and monitor the B/P and symptoms. QA confirmed an untreated high blood pressure could cause many complications and needed immediate attention. QA stated, “I agree, there are specific problems that cannot wait, and the physician should be called at the visit.” Kim: Patient 6 had new onset of edema in Rt ankle area. (Documented by PT and SN after full weight bearing, no update). Patient 3 had a fall with no physician update. During a review of Patient 3’s clinical record, Patient 3 was admitted to the home health agency on 5/13/24 with diagnoses that included heart failure, high blood pressure, weakness and falls. A review of Patient 3’s physicians plan of care indicated orders for skilled nursing (SN) one time a week for 2 weeks (1W2) and 2 prn (as needed) for a change of condition. There was also an order for Physical Therapy (PT) for one time a week (1wk1) to evaluate and treat. After the PT evaluation the services were ordered one time a week for 4 weeks (1W4). During a review of Patient 3’s record an Incident Log dated 5/22/24, showed a Registered Nurse documented during a home visit Patient 3 stated she had fallen stepping off the sidewalk and feel backwards on her back. She stated she was uninjured and she was helped by a bystander. Additionally, the RN documented this day Patient 3 was reaching in her refrigerator to put food away, lost balance and feel backwards and EMS (emergency medical response) was called. A review of a Physical Therapy (PT) visit note dated 5/22/24 (the same day) indicated Patient 3 informed the visiting PT she feel in the kitchen since her last visit attempting to put food away. There was no documentation of Patient 3’s physician being notified of her stated unwitnessed falls by the visiting RN or the PT. During an interview with the Clinical Supervisor (CS) on 3/27/25 at 1:45 pm she stated it is the agencies expectation that nursing staff are to notify the physician of falls. She concurrently stated she could not find any physician notification from nursing or therapy which saw Patient 3 the same day. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency on 3/4/25 with diagnoses that included a fractured right lower leg, atrial fibrillation (irregular heart rate), long term use of anticoagulants (blood thinners) and a history of falling. The plan of care indicated the skilled nurse would visit one time a week for three weeks (1wk3) and 2 prn (as needed) for change of condition and the Physical Therapy (PT) would visit after their evaluation for 1 time a week for 5 weeks (1wk5). The POC included that PT would assess functional status, structural barriers in the environment, rehabilitation potential, gait training, safety precautions, home exercise program and pain management. On 3/26/25 at 9:30 am a visit to Patient 6’s home was conducted with Physical Therapist (PT) E. Prior to entrance PT E stated Patient 6 is now full weight bearing to her right foot and was previously ordered non weight bearing. Patient 6 was observed sitting in her recliner with her legs elevated upon arrival. Concurrently at 9:40 am PT E stated Patient 6’s right foot had slight redness and swelling since his last visit. Patient 6 stated her right foot pain level was a “6” (a standardized pain scale of 1 to 10 with 1 being the least pain and 10 being the highest). PT E did not assess Patient 6’s pulses on her right foot (ensure circulation was adequate). A review of PT E's 3/26/25 visit note was reviewed after the visit. Under assessment, PT E documented he noted mild redness on Patient 6's right lateral malleolus (prominent bone on the outside of the ankle) and increased swelling since her previous session. He also indicated Patient 6 was having mild pain since she has been walking more. A follow up interview was conducted with PT E on 3/27/25 at 3:40 pm. He confirmed he did not notify Patient 6’s physician of her increased swelling and redness to her right ankle area. During a interview and record review with the CS on 3/27/25 at 4 pm she stated the physicians should be notified of any changes of condition. She stated the agency does have a doppler (a device that can detect blood flow) to check Patients pulses.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure 10 out of 10 patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and Patient 10) had Interdisciplinary (IDT, contributions of various health care disciplines and their interactions with each other to meet the patient's needs) ongoing assessments documented in the clinical record. This failure had the potential for unrecognized needs to go unmet with negative clinical outcomes. Findings: During a review of the agency’s policy not dated, titled, “Coordination of Care,” indicated the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and communication with the physician. This policy also indicated Coordination of care means assuring that the client needs are continually assessed, addressed in the plan of care (POC), that care is delivered in a timely and effective manner, and goals are achieved.” During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 5/31/24 with diagnoses that included left femur fracture (broken bone of the thigh, the largest bone in the body), Atrial Fibrillation (irregular and fast heart rate), congestive heart failure (long term condition when your heart cannot pump enough blood for the body’s needs), diabetes (too much sugar in the blood), anxiety (a feeling of worry, nervousness or fear), and acute embolism (sudden obstruction of a blood vessel that travels in the bloodstream). During a review of Patient 1’s clinical record, there were no IDT notes documented in Patient 1’s clinical record from 5/31/24 through 7/3/24, when Patient 1 was discharged from the agency. During a review of Patient 4’s clinical record, Patient 1 was admitted to the home health agency on 2/25/25 with diagnoses that included respiratory failure with hypoxia (serious lung condition when there is not enough oxygen in the blood), pneumonia (a lung infection with inflammation and fluid making it hard to breathe), chronic kidney disease stage 3 (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), myocardial injury (heart attack with heart damage), depression (persistent sadness, or loss of interest with activities that affect daily life), pulmonary embolism (condition when a blood clot travels to the lungs and blocks one or more blood vessels), and transient ischemic attacks (mini strokes, when the oxygen supply is briefly blocked in the brain resolving in minutes). During a review of Patient 4’s clinical record, there were no IDT notes documented in Patient 4’s clinical record from 2/25/25 through 3/27/25. During a review of Patient 5’s clinical record, Patient 1 was admitted to the home health agency on 4/15/24 with diagnoses that included Peripheral Venous Deficiency (PVD, circulation problem with reduced blood flow to the arms and legs, causing pain, tingling, and numbness), venous stasis ulcers (non-pressure open sores that develop on the les or ankles from poor circulation), Urinary Tract Infection (UTI, infection of the urinary tract, most common human bacterial infection) high blood pressure, cellulitis (inflammation and infection of the skin and underlying tissues), and history of falling. During a review of Patient 5’s clinical record, there were no IDT notes documented in Patient 5’s clinical record from 4/15/24 through 3/27/25. During a review of Patient 8’s clinical record, Patient 1 was admitted to the home health agency on 2/19/25 with diagnoses that included neoplasm of the liver (growth of tumor in the liver), liver disease (damaged liver which cleanses the blood and aids in digestion by secreting bile), diabetes (too much sugar in the blood), and elevated white blood cell (wbc) count (abnormal high number of wbcs, cells used to fight infection), hypothyroidism (underactive thyroid not producing enough hormones), and repeated falls. During a review of Patient 8’s clinical record, there were no IDT notes documented in Patient 8’s clinical record from 2/19/25 through 3/27/25. During a review of Patient 9’s clinical record, Patient 9 was admitted to the home health agency on 1/20/25 with diagnoses that included subdural hematoma, chronic stage 3 kidney disease (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), hypothyroidism, depression (persistent sadness, or loss of interest with activities that affect daily life), anxiety (a feeling of worry, nervousness or fear), post-traumatic stress disorder (PTSD, mental health condition after experiencing trauma, leading to persistent distress, anxiety, nightmares, and flashbacks), macular degeneration (progressive, gradual loss of central vision), and repeated falls. During a review of Patient 9’s clinical record, there were no IDT notes documented in Patient 9’s clinical record from 1/20/25 through 3/27/25. During an interview on 3/26/25 at 4:15 pm, the Administrative Assistant (AA) and the Quality Assurance Registered Nurse (QA) confirmed there were no IDT notes for case conference for any of the 10 sampled patients. QA confirmed IDT meetings are needed to discuss the patient needs, and revisions to provide quality care and individualized care of every patient on service. QA stated, “We will begin case conference meetings immediately in both branches and record in the medical record.” During a review of Patient 2’s clinical record, Patient 2 was admitted to the home health agency on 11/11/24 with diagnoses that included heart failure, diabetes and severe protein and calorie malnutrition. During a review of Patient 2’s clinical record, there were no IDT notes documented in Patient 2’s clinical record from 11/11/24 through 12/24/24, when Patient 2 was discharged from the agency. During a review of Patient 3’s clinical record, Patient 3 was admitted to the home health agency on 5/13/24 with diagnoses that included heart failure, high blood pressure, weakness and falls. During a review of Patient 3’s clinical record, there were no IDT notes documented in Patient 3’s clinical record from 5/13/24 through 6/21/24, when Patient 2 was discharged from the agency. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency on 3/4/25 with diagnoses that included a fractured right lower leg, atrial fibrillation (irregular heart rate), long term use of anticoagulants (blood thinners) and a history of falling. During a review of Patient 6’s clinical record, there were no IDT notes documented in Patient 6’s clinical record from 3/4/25 through 3/27/25. During a review of Patient 7’s clinical record, Patient 7 was admitted to the home health agency on 3/11/25 with diagnoses that included fractured left and right femur (thigh bone) history of falls, anemia, urinary tract infection and urinary incontinence. During a review of Patient 7’s clinical record, there were no IDT notes documented in Patient 7’s clinical record from 3/11/25 through to 3/27/25. During a review of Patient 10’s clinical record, Patient 10 was admitted to the home health agency on 2/21/25 with diagnoses that included heart failure, hypertension and history of falling. During a review of Patient 10s’s clinical record, there were no IDT notes documented in Patient 10s’s clinical record from 2/21/25 through to 3/27/25.

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 three of 10 sampled patients (Patient 3, 7, and 10), were evaluated by a discipline ordered by the referring physician in a timely manner included in the plan of care (POC), when Patient 1, 7, and 10’s Physical Therapy (PT) evaluation was late. This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight which could lead to negative clinical outcomes. Findings: Patient 3's record was reviewed. A review of Patient 3’s record indicated she had a referral date for admission for services from the agency on 5/6/24, and was admitted (start of care) on 5/13/24 (seven days later). Patient 3’s diagnoses included heart failure, high blood pressure, weakness and falls. A review, of Patient 3’s physician's plan of care included orders for for Physical Therapy (PT) for one time a week (1wk1) to evaluate and treat. The first PT visit was documented on 5/15/24 (nine days after the referral). A “Delay in Initial Assessment…(Start of Care)” dated 5/8/24, notifying the physician of the delay of SOC was presented during the survey, but failed to be signed by the physician. During an interview, with the Clinical Supervisor (CS) on 3/27/25 at 2 pm, she stated, that Patient 3's PT SOC was late. Patient 7's record was reviewed. Patient 7’s record indicated, that she had a referral date for admission for services from the agency on 3/6/25, and was admitted (start of care) on 3/11/25 (five days later). Patient 7’s diagnoses included fractured left and right femur (thigh bones) history of falls, anemia, urinary tract infection, and urinary incontinence. A review, of Patient 7’s physician's plan of care included for PT to visit one time a week (1wk1) to evaluate and treat. The first PT visit was documented on 3/17/24, eleven days after the referral. During an interview, and record review, with the CS on 3/27/25 at 4:10 pm, she acknowledged, that Patient 7’s PT SOC was late. Patient 10's record was reviewed. Patient 10’s record indicated, that she had a referral date for admission for services from the agency on 2/17/25, and was admitted (start of care) on 2/21/25 (four days later). Patient 10’s diagnoses included heart failure, hypertension and history of falling. A review, of Patient 10’s physician's plan of care indicated included orders for PT for one time a week (1wk1) to evaluate and treat. The first PT visit was documented on 2/26/25 (nine days from the referral date). During an interview, and record review, with the agency CS on 3/28/25 at 9:34 am, she acknowledged, that Patient 10’s SOC was late for physical therapy services.

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 agency failed to have an effective governing body (GB) legally responsible for establishing and implementing management and operational policies to ensure effective administration of the agency to provide care and services within acceptable standards of practice when the agency failed to: Ensure the Quality Assurance Performance Improvement (QAPI) is up to date, defined, implemented and maintained. Areas included in the QAPI are areas to track and trend infections, root cause analysis, falls, update the Medical Director at least annually and as needed, and to include clinical oversight for accuracy and positive clinical outcomes by using the Outcome and Assessment Information Set (Oasis) data to measure outcomes. Ensure there were care coordination conferences for all patients on service to discuss ongoing assessments of patients. Ensure the Executive Director, or Clinical Supervisor provided oversight to make decisions on accepting new home health referrals and initiating the initial assessment within 48-hours, or updating the physician before the start of care (SOC). Ensure there is a Director of Patient Care Services, or Clinical Supervisor on site in both branches to provide clinical oversight for all nurses and staff. Ensure there were a written copy of fingerprints available for the Administrator, and designee in the branch for the agency. Ensure there is a Clinical Laboratory Improvement Amendment (CLIA, allows facilities to perform simple, low risk laboratory tests while ensuring quality control compliance with federal regulations) waiver for labs obtained in both branches of the agency. These failures had the potential to lead to poor case management, and negative clinical outcomes. Findings: 1. During a concurrent interview, and record review, on 3/27/25 at 3:45 pm, the Administrative Assistant (AA), provided the most recent copy of their QAPI report. The AA confirmed they are working on a new process to track and trend infections, falls, and include all the needed components to measure patient outcomes. 2. During an interview, on 3/26/25 at 4:15 pm, the Administrative Assistant (AA), and the Quality Assurance Registered Nurse (QA) confirmed, that there were no IDT notes for case conference for any of the 10 sampled patients. The QA confirmed, that IDT meetings are needed to discuss the patient needs, and revisions to provide quality care and individualized care of every patient on service. 3. During an interview, on 3/28/25 at 10 am, the Clinical Supervisor (SC), confirmed that Patients 1, 3, 4, 5, 7, 9, and Patient 10, did not have a timely initiation of their SOC, and the physicians were not updated. 4. During a phone interview, on 3/28/25 at 12:25 pm, the Administrator, confirmed that he would provide needed clinical oversight for both branches of the agency, and utilize his present clinical supervisor with years of experience in home health. 5. During an interview, on 3/27/25 at 4:30 pm, the AA confirmed, that there were no written copy of fingerprints on file for the Administrator, and the designee, but both were completed. AA reported, they were done at the local police department, we are waiting on the copies to be sent. 6. During an interview, on 3/28/25 at 12 pm, the AA confirmed, that the agency does not have a CLIA waiver for both branches of the agency.

An Emergency Preparedness Survey was conducted by the California Department of Public Health (CDPH) from 7/11/22 through 7/14/22. The facility was not in substantial compliance with the requirement of §484.102, Emergency Preparedness Condition of Participation for Home Health Agencies. Representing the Department: 40484, Health Facilities Evaluator Nurse (HFEN), 39737, HFEN 45315, HFEN Census (unduplicated, 12-month period): 256

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to maintain their emergency preparedness plan when they did not review and update the plan every two years. This failure had the potential to contribute to an inadequate response during an emergency, and lead to a loss of well-being for patients and staff. Findings: During a review of the facility Emergency Plan, no record was found indicating a review or update was done by the facility. During an interview on 7/11/22 at 12:40 pm, the Office Manager (OM) confirmed that no review had been done for their emergency plan within the last two years.

**AMENDED** The following reflects the findings of the California Department of Public Health during a federal recertification survey conducted 7/11/22 through 7/14/22. Representing the Department: 40484, Health Facilities Evaluator Nurse (HFEN), 39737, HFEN 45315, HFEN Census (unduplicated, 12-month period): 256 Sample Size: 7 Home Visits: 3 Records Reviewed: 7 The following Conditions of Participation were not in compliance: G0680: Infection prevention and control

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to conduct an initial assessment within 48 hours of the referral, on two of seven sampled patients (Patient 4 and Patient 6). These failures had the potential to delay necessary treatment and could lead to a loss of well-being. 2. Patient 6 was admitted to the facility on 6/29/2022 with the diagnosis of pressure ulcer stage 2 (wound with open skin). A review of Patient 6’s record on 7/12/2022, indicated a signed physicians order to provide wound care was dated 6/23/2022. The fax notation indicated it was faxed to the facility on 6/23/2022, at 9:26 am. Patient 6’s Start of Care (SOC) assessment was dated 6/29/2022 and the initial order was dated 6/23/2022. During a concurrent interview and record review, on 7/12/2022, at 4:15 pm, Licensed Nurse (LN) A stated the facility is not always able to get out on time for the SOC and confirmed Patient 6 was opened 6 days after the initial order. During a concurrent interview and record review, on 7/12/2022, at 4:40 pm, Office Manager (OM) confirmed there was a 6 day delay in performing the initial SOC assessment and a physician order to delay the SOC had not been obtained prior to the SOC. A review of the facility’s undated policy and procedure (P&P) titled: “Client Admission Process” indicated “The initial assessment will be completed within forty-eight (48) hours of referral or within forty-eight (48) hours of the client’s return home, or on the physician ordered/client requested start of care date.” Findings: A review of the facility's undated policy and procedure (P&P) titled, “Client Admission Process” read, “The initial assessment will be completed within forty-eight (48) hours of referral or within forty-eight hours of the client’s return home, or on the physician ordered/client requested start of care date.” 1. Patient 4 was admitted to the facility on 5/18/22 with diagnoses that included kidney failure, metabolic encephalopathy (a chemical imbalance that affects the brain), and a history of falls. A record review of Patient 4’s admitting physician orders for Home Health, indicated a signed order dated 5/5/22 at 10:30 am. These orders were faxed to the agency 5/5/22 at 11:12 am. A review of Patient 4’s Start of Care (SOC) indicated that the SOC date was 5/18/22, 13 days after the initial order date. During a concurrent interview and record review on 7/12/22 at 4:23 pm, Office Manager (OM) verified the fax ordering Home Health, arrived on 5/5/22 to the main facility branch. OM indicated that she was on vacation that week and someone else would have had to fax the order to the secondary facility branch that would have admitted this patient. OM stated that the secondary facility branch only has one Registered Nurse (RN) to initiate SOC and that sometimes SOC is delayed because of staffing issues. The physician order had a notation that it was faxed to the secondary branch on 5/5/22. A record review of a document dated 5/10/22 and titled “Intake/Admission Screening Addendum and Updated Plan of Care” indicated “Delay in “Start of Care” or “Resumption of Care”, due to agency staffing/schedule. During a concurrent interview and record review at the secondary agency branch on 7/13/22 at 9 am, Licensed Nurse (LN) H verified that they had received the fax on 5/10/22 from the main agency. She indicated that the notes in the record indicated that the family was called on 5/11/22 to initiate SOC but did not return the call. A second message was left 5/13/22. Family returned the call on 5/16/22 and a SOC date was set for 5/18/22.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that services provided conformed with physician orders when orders for two of 7 sampled patients (Patient 4 and Patient 7) were not carried out as specified by the physician when Patient 4 missed a physical therapy visit on 5/26/22 and Patient 7 did not receive all Home Health Aide (HHA) visits as ordered by the physician. These failures had the potential to contribute to a loss of patient well-being by delaying or omitting essential care. Findings: 1. Patient 4 was admitted to the facility on 5/18/22 with diagnoses that included kidney failure, metabolic encephalopathy (a chemical imbalance that affects the brain), and a history of falls. A record review of Resident 4’s Plan of Care (POC) dated 5/18/22, indicated that Physical Therapy (PT) was to evaluate and treat the patient one time. A record review of Patient 4’s PT POC indicated that PT evaluated Patient 4 on 5/20/22 and ordered treatment one time per week for four weeks (1w4). A record review of PT documentation, indicated that Patient 4 had visits from PT on 6/1/22, 6/8/22, and 6/15/22. PT attempted to do a visit on 5/26/22, but charting indicated that no one answered the door and this resulted in a missed visit. Documentation of the 6/15/22 visit indicated the patient was discharged from PT on that date. During a concurrent interview and record review on 7/13/22 at 2:30 pm, Licensed Nurse (LN) A, agreed that Patient 4 had one evaluate and treat order for PT and that PT ordered four more treatments. She agreed that the evaluation and treatment order and the four treatment orders, made a total of five visits ordered for PT and that the patient only received four visits. During a concurrent phone interview and record review on 7/14/22 at 9:33 am, Physical Therapist D agreed that the first visit with Patient 4 was on 5/20/22 to evaluate and treat. She ordered 4 visits and she saw the patient on 6/1/22, 6/8/22 and 6/15/22. She stated she had a missed visit on 5/26/22. She stated this made four visits as ordered. PT D was informed that the initial order to evaluate and treat, plus her order to give four more treatments made a total of five visits. She stated the facility have been counting the evaluate and treat order in with the next order, which in Patient 4’s treatment would have made four treatments and not five. 2. Patient 7 was admitted to the facility on 6/1/22 with diagnoses that included hemiplegia (weakness or paralysis on one side of the body), fracture of sacrum (bone at bottom of spine), dysphagia (difficulty swallowing). A record review of the POC, dated 6/1/22, indicated an order for a Home Health Aide (HHA) to assist Patient 7 once a week for nine weeks, to provide personal care. A record review of the HHA Care Plan, dated 6/1/22 indicated that Patient 7 would have a HHA for nine weeks, once per week, and would assist with personal care such as vital signs, bathing, dre3ssing, turning and positioning, linen changes etc. A record review indicated documentation for HHA visits on 6/7/22 and 6/14/22. Both of these visits were performed by a facility Licensed Vocational Nurse, as the facility does not have HHA’s. No further HHA visits were noted. During a concurrent interview and record review with OM on 7/13/22 at 4:30 pm, OM stated that as the facility does not have HHA, sometimes they can not provide the services. OM stated nursing service is always more important. She agreed that Resident 7 did not receive some of the HHA visits as the facility did not have the staff available. During a concurrent phone interview and record review on 7/13/22 at 3:05 pm, LN G verified that she provided the HHA visits on 6/7/22 and 6/14/22 and that the facility does not have HHA’s. LN G stated the visits are scheduled by the office staff, and she was not scheduled time to do the HHA visit and the nursing visit, and just the nursing visit was done. During a concurrent interview and record review on 7/13/22 at 4:15 pm, LN A verified that Patient 7’s record indicated that only two HHA’s visits were done since 6/1/22 and that they were ordered weekly for nine weeks.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to document a verbal order for one of two patients (Patient 6) when wound care had been provided to Patient 6. This failure had the potential for incorrect wound care to be performed by other visiting nurses which could cause wound deterioration and a potential negative outcome. Findings: Patient 6 was admitted to the facility on 6/29/2022 with the diagnosis of pressure ulcer stage 2 (wound with open skin). During a concurrent interview and record review on 7/12/2022, at 4:15 pm, Licensed Nurse (LN) A stated on 6/29/2022, a phone call was placed to Patient 6’s doctor for new wound care orders during the home visit. LN A confirmed there was no documentation in the record or on the faxed order to support the doctor had been called or that a verbal order had been provided. A review of the agency’s undated policy and procedure titled: “Physician Orders” indicated “Orders may be initiated via telephone” and “The order must include the date, specific order, be signed with the full name and title of the person receiving the order and be sent to the physician for signature.”

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, interviews and record reviews, to follow accepted standards of practice to prevent the transmission of disease, when 1.a. The facility did not develop a P&P that included COVID-19 vaccination of facility staff. 1.b. Contingency plans (alternate plan) that include additional precautions for COVID-19 unvaccinated staff. 1.c. Medical exemption (reason for not getting the vaccination) and medical delay (reason to get vaccinated at a later date) forms did not include required documentation stating which COVID-19 vaccine was clinically contraindicated (medical reason to not receive the vaccination) and was missing a statement from the provider that included the recognized clinical reason for the contraindication. 1.d. Did not have a process to accurately track staff COVID-19 vaccination status, medical or spiritual exemptions (exemptions), and medical delays. Staff included but not limited to individuals who provide direct resident care from outside sources. 2. Facility staff were not provided with in-services or education regarding new requirements for COVID-19 staff vaccination as outlined in the Quality Safety & Oversight memoranda 22-07-ALL (QSO, The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring the health and safety of facility patients by enforcing the standards required to help each patient attain or maintain their highest level of well-being) revised 4/5/2022. CMS is committed to ensuring America's healthcare facilities respond effectively in an evidence-based way to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE). 3. Bag technique was not followed during an observed home visit, and 4. Supplies available for use in the facility supply room were expired. The cumulative effect of these systemic problems resulted in the agency's inability to ensure that the agency provided accepted standards of infection control and was likely to cause serious injury, harm, impairment, or death to a patient. Refer to G682 and G687.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow accepted standards of practice to prevent the transmission of disease when Bag technique was not followed during an observed home visit, andSupplies available for use in the facility supply room were expired. These failures had 1. the potential to contribute to the transmission of disease among patients and staff; and 2. the potential for unsafe medication use, and the use of medical tests and supplies which would no longer be effective, which could lead to negative clinical outcomes. 2. During a concurrent interview and observation in the facility's active supply room, on 7/13/2022, at 3:49 pm, accompanied by Office Manager (OM) and Licensed Nurse (LN) A, the following items were stored in the active supply room and available for use: 6 boxes of iHealth COVID-19 (an illness that can cause severe symptoms and in some cases death, especially in the elderly) rapid test kits, expired 5/2022.1 bottle Dyna-hex-2 (a hand cleanser used to reduce germs), expired 9/2021. 3 cans of hand sanitizer foam (a hand cleanser used to reduce germs), expired 3/2022.2 Heparin flushes (blood thinning medication injected into the vein), expired 11/2018.2 boxes of Dynarex Alcohol Swabsticks (used to cleanse a variety of items, to reduce germs), expired 4/2021.1 box of Curad Triple Antibiotic Ointment (medication for small scratches/cuts to reduce germs), expired 3/2022. OM and LN A confirmed findings of expired items located in the active storage area. A review of the undated policy and procedure (P&P), titled: “Equipment and Supplies Management” indicated “Manufacturer’s expiration dates will be strictly adhered to.” Findings: A review of an undated facility document titled “Nursing Bag”, indicated that supplies used during a home visit must be maintained in a clean environment. The nursing bag must be placed on a barrier, which is placed on a clean dry surface in the home; and all items removed from the bag must be cleaned before returning them to the bag. A review of Centers for Disease Control (CDC) Hand Hygiene Guidance at https://www.cdc.gov/handhygiene/providers/guideline.html indicated that hand hygiene must be performed before and after touching a patient, and immediately after glove removal. A review of the clinical record indicated that Patient 3 was admitted on 6/7/22 with diagnoses of left heel pressure wound, diabetes, and heart disease, and required weekly nursing services. During an observation of a home visit with Patient 3 on 7/12/22 at 10:20 am, Licensed Nurse (LN) B placed a barrier on a table, then placed the nursing bag on the barrier. LN B then removed equipment from the bag and placed it directly on the patient’s table, without using a barrier. Then, while preparing to provide wound care, LN B wore clean gloves, placed the wound care supplies on a new barrier, then donned her glasses and pushed her hair back while wearing the clean gloves. LN B then proceeded to remove the old dressing from the wound while wearing the same gloves. After measuring the wound, LN B changed gloves without performing hand hygiene. After the wound care was complete, LN B doffed the gloves, performed hand hygiene with a sanitizing wipe, then used the same wipe to sanitize the bandage scissors before placing them back in the nursing bag. During an interview on 7/12/22 at 11:30 am, LN B confirmed the breaches of bag technique and hand hygiene made during the visit.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on Interviews and record reviews, the facility failed to develop and implement a policy and procedure (P&P) to ensure all facility staff who provide any care, treatment, or other services for the facility and/or its patients are fully vaccinated for COVID-19 (an illness that can cause severe symptoms and in some cases death, especially in the elderly) when: 1.a. The facility did not develop a P&P that included COVID-19 vaccination of facility staff. 1.b. Contingency plans (alternate plan) that include additional precautions for COVID-19 unvaccinated staff. 1.c. Medical exemption (reason for not getting the vaccination) and medical delay (reason to get vaccinated at a later date) forms did not include required documentation stating which COVID-19 vaccine was clinically contraindicated (medical reason to not receive the vaccination) and was missing a statement from the provider that included the recognized clinical reason for the contraindication. 1.d. Did not have a process to accurately track staff COVID-19 vaccination status, medical or spiritual exemptions (exemptions), and medical delays. Staff included but not limited to individuals who provide direct resident care from outside sources. 2. Facility staff were not provided with in-services or education regarding new requirements for COVID-19 staff vaccination as outlined in the Quality Safety & Oversight memoranda 22-07-ALL (QSO, The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring the health and safety of facility patients by enforcing the standards required to help each patient attain or maintain their highest level of well-being) revised 4/5/2022. CMS is committed to ensuring America's healthcare facilities respond effectively in an evidence-based way to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE). This failure resulted in the provider's noncompliance with one or more requirements of participation and was likely to cause serious injury, harm, impairment, or death to a patient. Findings: 1.a. A review of Attachment G of the QSO indicated "the HHA must develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19." The QSO indicated the deadline was 3/1/2022 for all facilities to become 100 percent (%) compliant with the regulation. During a concurrent interview and record review, on 7/14/2022, at 10:14am, Office Manager (OM) stated a policy for COVID-19 staff vaccination requirements could not be located. A review of the staff vaccination records indicated 95% staff COVID-19 vaccination rate. During an interview, on 7/14/2022, at 9:27 am, OM confirmed Physical Therapist I (PT) had not received the COVID-19 vaccination and did not have a medical exemption or medical delay on file. 1.b. A review of Attachment G of the QSO, revised 4/5/2022, indicated "the policies and procedures must include, at a minimum, the following components... contingency plans for staff who are not fully vaccinated for COVID-19.” “A process for ensuring the implementation of additional precautions…for all staff who are not fully vaccinated for COVID-19.” During a concurrent interview and record review, on 7/14/2022, at 10:14 am, OM stated no contingency plan was in place for COVID-19 unvaccinated staff. 1.c. A review of Attachment G of the QSO, revised 4/4/2022, indicated "the policies and procedures must include, at a minimum, the following components..."a process by which staff may request and exemption from the staff COVID-19 vaccination requirements", a process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner", "all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated", "the reason why", and "a statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the clinical contraindications." During a concurrent interview and record review, on 7/14/2022, at 10:14 am, OM confirmed the medical exemption for Licensed Nurse F (LN) did not include which COVID-19 vaccine was clinically contraindicated and was missing required information from the provider. 1.d. A review of Attachment G of the QSO, revised 4/5/2022, indicated "the policies and procedures must include, at a minimum, the following components...a process for tracking and securely documenting the COVID-19 vaccination status of all staff" and “a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended." During a concurrent interview and record review, on 7/14/2022, at 10:14 am, OM confirmed there was no process in place to track and securely document the COVID-19 status of all staff. 2. During an interview, on 7/14/2022, at 10:14 am, OM was not able to provide a log for in-services and stated that it had been a “long time” since in-services had been done and could not confirm if the agency staff had been educated on the requirements for staff COVID-19 vaccination. During an interview on 7/13/2022, at 10:41 am, LN G stated COVID-19 in-services occurred “in the beginning” of COVID-19 and was not able to recall the year in-services or education had last been provided by the agency. During an interview on 7/13/2022, at 11:43 am, LN B was unable to state when the last in-service or training for COVID-19 had occurred. LN B stated emails had been sent by the previous facility owner throughout the years 2020 and 2021 and was unsure if any educational emails had been sent for the current year (2022). During an interview on 7/13/2022, at 1:03 pm, PT H stated there had not been an in-service for COVID-19 other than the education provided during the on-boarding process (education/training for new hires). PT H stated being hired May 2021.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to perform any ongoing interdisciplinary assessment of their patients when no case conference notes were found in seven of seven clinical records reviewed. This failure had the potential to lead to loss of well-being for patients when staff are unaware of and do not coordinate with the care provided by other disciplines. Findings: A review of an undated facility document titled “Coordination of Service” indicated that the facility staff must communicate with each other to evaluate patient progress and revise treatment goals as needed, and this communication must be documented in a complete and timely manner. During reviews of clinical records for sampled patients, survey staff were unable to locate any case conference notes in the record for any patient. During an interview on 7/12/22 at 4:35 pm, Licensed Nurse (LN) A stated that the facility used to hold case conference meetings, but have not done that for some time. LN A confirmed there were no case conference meetings documented in patients’ records.