Every finding on record at Reliant First Healthcare Services Inc

A recertification survey and complaint investigation (Intake #521444) was conducted on 02/06/2025. The census was: LCHHS: 28 LHHS: 0 PAS: 14 The agency was found in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A recertification survey and complaint investigation (Intake #521444) was conducted on 02/06/2025. The census was LCHHS: 28 LHHS: 0 PAS: 14 Abbreviations: Adm = Administrator Alt Adm = Alternate Administrator AM - Ante meridiem CFR = code of federal regulations chemo = chemotherapy DON = director of nursing LCHHS = licensed and certified home health services LHHS = licensed home health services LVN = licensed vocational nurse MD = Medical Doctor NP = nurse practitioner PAS = personal assistance services PM = Post meridiem Prn = as needed QIO = quality improvement organization TAC – Texas Administrative Code

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the proper written Notice of Medicare Non-Coverage no later than two days in advance of terminating on-going care that included the correct QIO telephone number and the patient or representative signature in two of two discharge records reviewed whose reason for discharge was goals met (Patient 3 and 4). This failure had the potential to result in patients being unable to contact the QIO in the event they chose to exercise their right to appeal the discharge decision. This failure failed to protect the rights of the patients and to ensure the implementation of agency policy and procedures related to the discharge of agency patients. Findings included: Regulation: July 1, 2005, the Medicare regulations (Benefits Improvement and Protection Act) BIPA gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The phone number for the QIO should be included in this notice (888-315-0636). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. A patient discharge list with discharge reason was provided to the surveyor by the Adm on 02/06/2025. During an interview with the Adm at the entrance conference on 02/06/2025 at 12:45 PM, the Adm stated he was responsible for ensuring correct information was included on the discharge notice titled, “Notice of Medicare Non-Coverage.” Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024. The discharge list included Patient 3’s discharge date was 12/04/2024 with a discharge reason of goals met. Record review of the clinical record contained the Centers for Medicare and Medicaid Services form titled, "Notice of Medicare Non-Coverage." The form read in part, " ...The effective date coverage of your Current Home Health Services Will End: ... 12/04/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…" The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 3 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 3 or representative should have signed the form to indicate an understanding of the notice. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The discharge list included Patient 4’s discharge date was 08/02/2024 with a discharge reason of goals met. The clinical record contained the Centers for Medicare and Medicaid Services form titled, "Notice of Medicare Non-Coverage." The form read in part, " ...The effective date coverage of your Current Home Health Services Will End: ... 08/02/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…" The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 4 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 4 or representative should have signed the form to indicate an understanding of the notice. During an interview with the DON on 02/14/2025 at 11:26 AM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The DON stated she usually had the patients sign the notice when she made the discharge visit, but that was not the case with Patients 3 and 4. The DON stated when licensed vocational nurses conducted visits during the episode, the licensed vocational nurses needed to give the notice. The DON stated she did not know the QIO’s phone number had changed. The DON stated the Adm was responsible for ensuring the correct information was included on the Notice of Medicare Non-Coverage form. The surveyor asked why areas of non-compliance were not identified and included in quality assurance activities and why agency policies were not followed. The DON stated they must have missed the issues and would try to go through everything to ensure the agency was in compliance. The DON further stated she would be more diligent going forward. During an interview with the Adm on 02/14/2025 at 3:00 PM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The Adm stated he did not have an answer and that it had been overlooked. The Adm stated he was unaware of the issues. During a telephone interview with the Adm on 02/14/2025 at 3:16 pm, the Adm stated agency polices were not followed because they were things the agency overlooked. Agency policy titled, “Policy 4.20: DISCHARGE/TRANSFER/REFERRAL OF PATIENTS” undated, read in part, “… PURPOSE… To uphold the patient's right to receive information about his/her care, treatment and services and to be involved in the decision-making process when appropriate… POLICY… Any discharge, transfer or referral of patients shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and in such a way as to prevent harm to the patient… The patient/family shall be an active participant, when possible, in planning his/her referral, transfer and/or discharge…” Agency policy titled, “Policy 4.21: CRITERIA FOR DISCHARGE - TRANSFER/DISCHARGE SUMMARY” undated, read in part, “… PURPOSE: To ensure a standardized process for discharging patients… To uphold the patient's right to receive information about his/her care, treatment and/or services and to be involved in the decision-making process when appropriate… POLICY: Any discontinuation of care, treatment and/or services should be done in an appropriate manner and in such a way as to prevent harm to the patient… The patient should be an active participant, when possible, in planning his/her referral, transfer and/or discharge…”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: This is a continuing deficiency from the survey dated 02/25/2022 cited at G0574. Based on record review and interview, the agency failed to ensure the plan of care included all pertinent diagnoses; the frequency of visits to be made; safety measures to protect against injury and patient-specific interventions in four of ten records reviewed (Patient 1, 2, 3, and 4) in that: a. In one of ten records reviewed (Patient 1), the plan of care did not include a diagnosis for an implantable infusion port (a central line implanted under the skin used for medication administration) and dialysis shunt (also known as a graft or fistula; A surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body); the type and location of the implantable infusion port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit (a rumbling sound that you can hear with a stethoscope over the area of a dialysis shunt) and thrill (vibration on the skin over the area of a dialysis shunt). b. In one of ten records reviewed (Patient 2), the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. c. In one of ten records reviewed (Patient 3), the plan of care did not include bleeding precautions and safety measures for a blood thinner medication. d. In one of ten records reviewed (Patient 4), the plan of care did not include the frequency of nursing visits. These failures placed patients at risk of harm from agency staff who could not address the patient's risk factors and type of services needed for appropriate care, placing patients at risk of declining health status and the potential for hospitalizations and long-term care facility placement. Findings included: According to Nursing2025 Protecting a Hemodialysis Fistula https://journals.lww.com/nursing/citation/2002/11000/protecting_a_hemodialysis_fistula.8.aspx November 18, 2002. Feel for a thrill (vibration on the skin over the area of turbulent blood flow) by touching the fistula and listen for a bruit (a rumbling sound that you can hear with a stethoscope). Assess the fistula for signs and symptoms of infection. Don’t take blood pressures on the access arm as it can contribute to infection and clotting in the fistula. According to https://www.inogen.com/blog/10-home-oxygen-safety-tips/ February 8, 2021. Home oxygen safety is one of the most important aspects of oxygen therapy. Although oxygen is a safe, non-flammable gas, it does support combustion, meaning things burn more readily and ignite easier in its presence. As such, you must be careful to follow oxygen safety in the home, and to make sure anyone in your home is aware of oxygen tank safety. According to WebMD https://www.webmd.com/dvt/blood-thinner-tips January 22, 2025. bleeding safety precautions while taking a blood thinner include: Take good care when you exercise or are active. Even a minor cut may bleed a lot if you’re on these medications. Wear gloves when you use sharp objects like scissors, knives, and gardening tools. Switch to an electric razor. You’re less likely to nick your skin. Wear sturdy shoes as often as possible -- always when you mow the lawn or garden. Use a soft toothbrush and waxed dental floss to clean your teeth. They’re easier on your gums. During the entrance conference with the Adm on 02/06/2025 at 12:45 pm, the Adm stated he was responsible for ensuring the plan of cares included required elements. Patient 1: Record review of the medical record included a plan of care dated 11/20/2024 to 01/18/2025 signed by the DON on 11/18/2024. The plan of care included a diagnosis of high blood pressure with chronic kidney disease and dependence on dialysis with a nursing visit frequency of once weekly for nine weeks. The plan of care read in part, “…assess permacath (a special IV device/catheter inserted in a blood vessel for the administration of medications (infusion port) or a dialysis shunt/graft/fistula)site every visit and prn including signs and symptoms of infection to site…” The plan of care did not indicate what the permacath was; what it was used for; or where it was located. The plan of care did not include a diagnosis for an implantable infusion port (a central line implanted under the skin used for medication administration) and dialysis shunt; the type or location of the implantable infusion port site; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit and thrill. The record included a recertification nursing assessment signed and dated by the DON on 11/18/2024 that included the patient had a dialysis shunt/graft/fistula. The assessment did not include where the shunt/graft/fistula was located. The record included a house call visit note signed and dated by NP on 10/30/2024 that read in part, “… reports a recent diagnosis of rectal cancer diagnosed in 2023 and underwent surgery, chemo….” The record included a nursing visit note signed and dated by LVN A on 11/22/2024 that read in part, “… hemodialysis… has a port to his right upper chest he used before for chemo…” During an interview with the DON on 02/14/2025 at 10:54 am, the DON stated she was responsible for ensuring the patient’s plan of care included all required elements and she tried to review the plan of cares before signing them but did not review them all the time. The DON stated she needed to do better. The DON further stated the patient had a dialysis catheter and a chemo port. The DON stated the permacath was the dialysis shunt where the patient received dialysis treatments. The surveyor asked why the plan of care did not include a diagnosis for an implantable infusion port and dialysis shunt; the type and location of the implantable infusion/chemo port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt; safety measures for the dialysis shunt and for the nurse to assess the dialysis shunt for a bruit and thrill. The DON stated she tried to put all the information on the plan of care but she did not think the plan of care was populating and pulling the information from the recertification assessment like it was supposed to. The DON stated she reviewed the plan of care and the 11/18/2024 assessment but the information was not included. The DON stated the plan of care did include orders to assess for signs and symptoms of infection, but the order was not specific and she needed to do better. Patient 2: Record review of the medical record included a plan of care dated 12/02/2024 to 01/30/2025 signed by the DON on 11/27/2024 and included a diagnosis of dependence on oxygen and a blood thinning medication, Clopidogrel, to be taken once daily. The plan of care included a nursing visit frequency of once weekly for nine weeks. The plan of care did not include oxygen safety measures; bleeding precautions and safety measures for the blood thinner medication. The record included a medical doctor visit note dated 12/04/2024 and signed by MD on 12/05/2024 that included the patient was on a blood thinning medication, Clopidogrel, and continuous oxygen. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor asked why the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. The DON stated she missed adding the information to the plan of care. Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024 and included the medication, Eliquis (blood thinner) to be taken twice daily. The plan of care included a diagnosis of long term use of a blood thinner and a nursing visit frequency of once weekly for nine weeks. The plan of care did not include bleeding precautions and safety measures for the blood thinner medication. During an interview with the DON on 02/14/2025 at 11:18 am, the surveyor asked why the plan of care did not include bleeding precautions and safety measures for the blood thinner medication. The DON stated she missed including the information on the plan of care. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The plan of care included a diagnosis of arthritis and high blood pressure. The plan of care did not include the frequency of nursing visits. During an interview with the DON on 02/14/2025 at 11:22 am, the surveyor asked why the plan of care did not include the frequency of nursing visits. The DON stated she missed including the information on the plan of care, but it should have been included. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The DON stated they tried including everything on the plan of cares, but they really needed to work on the issue. During a telephone interview with the Adm on 02/14/2025 at 3:04 pm, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The Adm stated he believed the agency corrected the problem but it seemed the issues were still occurring. The Adm further stated after the 2022 survey, the agency staff talked as a team about the plan of cares and everybody agreed on what should be done. During a telephone interview with the Adm on 02/14/2025 at 3:16 pm, the Adm stated agency policies were not followed because they were things the agency overlooked. Agency policy titled “Policy 4.16: Care Planning” undated, read in part, “PURPOSE: To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes. POLICY: The plan of care is developed and documented by the Registered Nurse… PROCEDURE: Each discipline, i.e., nursing, therapies, social work, including contracted services, develops a plan of care based on the assessment of patient needs and clinical status at the time of the initial/ admission visit… The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient's needs and clinical status, and promotes positive outcomes and avoids duplication of services… Each member of the healthcare team reviews the plan of care at least every two (2) weeks and more often if necessary, based on patient needs and clinical status to evaluate the appropriateness of the plan and the patient's progress toward goals… The healthcare team member updates the plan of care as necessary…” Agency policy titled “Policy 4.9: Assessment” undated, read in part, “PURPOSE To identify the patient's needs for care, treatment and/or services within an appropriate time frame based on the patient's needs and complexity of treatment. To determine the appropriate care, treatment and/or services to meet the patient's initial needs, as well as his/her changing needs… To ensure that the patient's current needs and/or problems are continuously evaluated and the care, treatment and/or services provided are adjusted accordingly… Data obtained during assessment visits is used to determine the patient's needs for care, treatment and/or services and to develop a plan of care… A proposed plan of care, based upon assessment findings, is developed and discussed with the patient and/or significant other… The comprehensive assessment is updated and revised by the appropriate skilled professional: To ensure that the plan of care is appropriately individualized to meet the patient's needs… The Comprehensive Assessment… Includes the following information… The patient's problems, needs… Pertinent diagnoses… A proposed plan of care/clinical pathway is developed and discussed with the patient/family/significant other… The completed plan of care is submitted to the Director of Patient Care Services/Intake Coordinator/ Clinical Supervisor/Performance Improvement Department within 24 hours of receipt of the information in the Data Entry Department for review as to accuracy and completeness…”

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Adm failed to carry out, organize and direct the agency's ongoing functions in that: 1. The Adm failed to provide oversight to ensure the plan of care included all pertinent diagnoses; the frequency of visits to be made; safety measures to protect against injury and patient-specific interventions in four of ten records reviewed (Patient 1, 2, 3, and 4) in that: a. In one of ten records reviewed (Patient 1), the plan of care did not include a diagnosis for an implantable infusion port (a central line implanted under the skin used for medication administration) and dialysis shunt (also known as a graft or fistula; A surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body); the type and location of the implantable infusion port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit a rumbling sound that you can hear with a stethoscope over the area of a dialysis shunt and thrill (vibration on the skin over the area of a dialysis shunt). b. In one of ten records reviewed (Patient 2), the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. c. In one of ten records reviewed (Patient 3), the plan of care did not include bleeding precautions and safety measures for a blood thinner medication. d. In one of ten records reviewed (Patient 4), the plan of care did not include the frequency of nursing visits. 2. The Adm failed to ensure the written Notice of Medicare Non-Coverage included the correct QIO telephone number and the patient or representative signature in two of two discharge records reviewed whose reason for discharge was goals met (Patient 3 and 4). 3. The agency's Adm and Alt Adm failed to complete 12 hours of continuing education in the required topics within each 12 months in that job as required for the position of the Adm and Alt Adm of an agency in two of two records reviewed for continuing education requirements (Adm and Alt Adm). These failures showed lack of overall administrative leadership, ineffective or improper management of the agency's operations and oversight that could negatively impact and protect the rights and safety of agency patients and staff. Findings included: 1. According to Nursing2025 Protecting a Hemodialysis Fistula https://journals.lww.com/nursing/citation/2002/11000/protecting_a_hemodialysis_fistula.8.aspx November 18, 2002. Feel for a thrill by touching the fistula and listen for a bruit. Assess the fistula for signs and symptoms of infection. Don’t take blood pressures on the access arm as it can contribute to infection and clotting in the fistula. According to https://www.inogen.com/blog/10-home-oxygen-safety-tips/ February 8, 2021. Home oxygen safety is one of the most important aspects of oxygen therapy. Although oxygen is a safe, non-flammable gas, it does support combustion, meaning things burn more readily and ignite easier in its presence. As such, you must be careful to follow oxygen safety in the home, and to make sure anyone in your home is aware of oxygen tank safety. According to WebMD https://www.webmd.com/dvt/blood-thinner-tips January 22, 2025. bleeding safety precautions while taking a blood thinner include: Take good care when you exercise or are active. Even a minor cut may bleed a lot if you’re on these medications. Wear gloves when you use sharp objects like scissors, knives, and gardening tools. Switch to an electric razor. You’re less likely to nick your skin. Wear sturdy shoes as often as possible -- always when you mow the lawn or garden. Use a soft toothbrush and waxed dental floss to clean your teeth. They’re easier on your gums.During the entrance conference with the Adm on 02/06/2025 at 12:45 pm, the Adm stated the DON was responsible for ensuring the plan of cares included required elements. Patient 1: Record review of the medical record included a plan of care dated 11/20/2024 to 01/18/2025 signed by the DON on 11/18/2024. The plan of care included a diagnosis of high blood pressure with chronic kidney disease and dependance on dialysis with a nursing visit frequency of once weekly for nine weeks. The plan of care read in part, “…assess permacath (a special IV device/catheter inserted in a blood vessel for the administration of medications (infusion port) or a dialysis shunt/graft/fistula) site every visit and prn including signs and symptoms of infection to site…” The plan of care did not indicate what the permacath was; what it was used for; or where it was located. The plan of care did not include a diagnosis for an implantable infusion port and dialysis shunt; the type or location of the implantable infusion port site; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit and thrill. The record included a recertification nursing assessment signed and dated by the DON on 11/18/2024 that included the patient had a dialysis shunt/graft/fistula. The assessment did not include where the shunt/graft/fistula was located. The record included a house call visit note signed and dated by NP on 10/30/2024 that read in part, “… reports a recent diagnosis of rectal cancer diagnosed in 2023 and underwent surgery, chemo….” The record included a nursing visit note signed and dated by LVN A on 11/22/2024 that read in part, “… hemodialysis… has a port to his right upper chest he used before for chemo…” During an interview with the DON on 02/14/2025 at 10:54 am, the DON stated she was responsible for ensuring the patient’s plan of care included all required elements and she tried to review the plan of cares before signing them but did not review them all the time. The DON stated she needed to do better. The DON further stated the patient had a dialysis catheter and a chemo port. The DON stated the permacath was the dialysis shunt where the patient received dialysis treatments. The surveyor asked why the plan of care did not include a diagnosis for an implantable infusion port and dialysis shunt; the type and location of the implantable infusion/chemo port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt; safety measures for the dialysis shunt and for the nurse to assess the dialysis shunt for a bruit and thrill. The DON stated she tried to put all the information on the plan of care but she did not think the plan of care was populating and pulling the information from the recertification assessment like it was supposed to. The DON stated she reviewed the plan of care and the 11/18/2024 assessment but the information was not included. The DON stated the plan of care did include orders to assess for signs and symptoms of infection, but the order was not specific and she needed to do better. Patient 2: Record review of the medical record included a plan of care dated 12/02/2024 to 01/30/2025 signed by the DON on 11/27/2024 and included a diagnosis of dependence on oxygen and a blood thinning medication, Clopidogrel, to be taken once daily. The plan of care included a nursing visit frequency of once weekly for nine weeks. The plan of care did not include oxygen safety measures; bleeding precautions and safety measures for the blood thinner medication. The record included a medical doctor visit note dated 12/04/2024 and signed by MD on 12/05/2024 that included the patient was on a blood thinning medication, Clopidogrel, and continuous oxygen. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor asked why the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. The DON stated she missed adding the information to the plan of care. Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024 and included the medication, Eliquis (blood thinner) to be taken twice daily. The plan of care included a diagnosis of long term use of a blood thinner and a nursing visit frequency of once weekly for nine weeks. The plan of care did not include bleeding precautions and safety measures for the blood thinner medication. During an interview with the DON on 02/14/2025 at 11:18 am, the surveyor asked why the plan of care did not include bleeding precautions and safety measures for the blood thinner medication. The DON stated she missed including the information on the plan of care. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The plan of care included a diagnosis of arthritis and high blood pressure. The plan of care did not include the frequency of nursing visits. During an interview with the DON on 02/14/2025 at 11:22 am, the surveyor asked why the plan of care did not include the frequency of nursing visits. The DON stated she missed including the information on the plan of care, but it should have been included. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The DON stated they tried including everything on the plan of cares, but they really needed to work on the issue. During a telephone interview with the Adm on 02/14/2025 at 3:04 pm, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The Adm stated he believed the agency corrected the problem but it seemed the issues were still occurring. The Adm further stated after the 2022 survey, the agency staff talked as a team about the plan of cares and everybody agreed on what should be done. Agency policy titled “Policy 4.16: Care Planning” undated, read in part, “PURPOSE: To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes. POLICY: The plan of care is developed and documented by the Registered Nurse… PROCEDURE: Each discipline, i.e., nursing, therapies, social work, including contracted services, develops a plan of care based on the assessment of patient needs and clinical status at the time of the initial/ admission visit… The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient's needs and clinical status, and promotes positive outcomes and avoids duplication of services… Each member of the healthcare team reviews the plan of care at least every two (2) weeks and more often if necessary, based on patient needs and clinical status to evaluate the appropriateness of the plan and the patient's progress toward goals… The healthcare team member updates the plan of care as necessary…” Agency policy titled “Policy 4.9: Assessment” undated, read in part, “PURPOSE To identify the patient's needs for care, treatment and/or services within an appropriate time frame based on the patient's needs and complexity of treatment. To determine the appropriate care, treatment and/or services to meet the patient's initial needs, as well as his/her changing needs… To ensure that the patient's current needs and/or problems are continuously evaluated and the care, treatment and/or services provided are adjusted accordingly… Data obtained during assessment visits is used to determine the patient's needs for care, treatment and/or services and to develop a plan of care… A proposed plan of care, based upon assessment findings, is developed and discussed with the patient and/or significant other… The comprehensive assessment is updated and revised by the appropriate skilled professional: To ensure that the plan of care is appropriately individualized to meet the patient's needs… The Comprehensive Assessment… Includes the following information… The patient's problems, needs… Pertinent diagnoses… A proposed plan of care/clinical pathway is developed and discussed with the patient/family/significant other… The completed plan of care is submitted to the Director of Patient Care Services/Intake Coordinator/ Clinical Supervisor/Performance Improvement Department within 24 hours of receipt of the information in the Data Entry Department for review as to accuracy and completeness…” Regulation: July 1, 2005, the Medicare regulations (Benefits Improvement and Protection Act) BIPA gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The phone number for the QIO should be included in this notice (888-315-0636). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. A patient discharge list with discharge reason was provided to the surveyor by the Adm on 02/06/2025. During an interview with the Adm at the entrance conference on 02/06/2025 at 12:45 PM, the Adm stated he was responsible for ensuring correct information was included on the discharge notice titled, “Notice of Medicare Non-Coverage.” Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024. The discharge list included Patient 3’s discharge date was 12/04/2024 with a discharge reason of goals met. The clinical record contained the Centers for Medicare and Medicaid Services form titled, "Notice of Medicare Non-Coverage." The form read in part, " ...The effective date coverage of your Current Home Health Services Will End: ... 12/04/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…" The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 3 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 3 or representative should have signed the form to indicate an understanding of the notice. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The discharge list included Patient 4’s discharge date was 08/02/2024 with a discharge reason of goals met. The clinical record contained the Centers for Medicare and Medicaid Services form titled, "Notice of Medicare Non-Coverage." The form read in part, " ...The effective date coverage of your Current Home Health Services Will End: ... 08/02/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…" The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 4 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 4 or representative should have signed the form to indicate an understanding of the notice. During an interview with the DON on 02/14/2025 at 11:26 AM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The DON stated she usually had the patients sign the notice when she made the discharge visit, but that was not the case with Patients 3 and 4. The DON stated when licensed vocational nurses conducted visits during the episode, the licensed vocational nurses needed to give the notice. The DON stated she did not know the QIO’s phone number had changed. The DON stated the Adm was responsible for ensuring the correct information was included on the Notice of Medicare Non-Coverage form. The surveyor asked why areas of non-compliance were not identified and included in quality assurance activities and why agency policies were not followed. The DON stated they must have missed the issues and would try to go through everything to ensure the agency was in compliance. During an interview with the Adm on 02/14/2025 at 3:00 PM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The Adm stated he did not have an answer and that it had been overlooked. The Adm stated he was unaware of the issues. Agency policy titled, “Policy 4.20: DISCHARGE/TRANSFER/REFERRAL OF PATIENTS” undated, read in part, “… PURPOSE… To uphold the patient's right to receive information about his/her care, treatment and services and to be involved in the decision-making process when appropriate… POLICY… Any discharge, transfer or referral of patients shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and in such a way as to prevent harm to the patient… The patient/family shall be an active participant, when possible, in planning his/her referral, transfer and/or discharge…” Agency policy titled, “Policy 4.21: CRITERIA FOR DISCHARGE - TRANSFER/DISCHARGE SUMMARY” undated, read in part, “… PURPOSE: To ensure a standardized process for discharging patients… To uphold the patient's right to receive information about his/her care, treatment and/or services and to be involved in the decision-making process when appropriate… POLICY: Any discontinuation of care, treatment and/or services should be done in an appropriate manner and in such a way as to prevent harm to the patient… The patient should be an active participant, when possible, in planning his/her referral, transfer and/or discharge…” The 84th Texas Legislature, 2015, transferred programs and services from the Department of Aging and Disability Services to the Health and Human Services Commission effective September 1, 2017. Rule Chapters for Home and Community Support Services Agencies moved from TAC, Title 40, Part 1, Department of Aging and Disability Services, to TAC, Title 26, Part 1, Health and Human Services Commission as of May 1, 2019. 40 TAC Chapter 97 was transferred to 26 TAC Chapter 558. Record review of the online Texas Unified Licensure Information Portal (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) on 02/21/2025 included: The Adm was appointed the Adm (Texas Unified Licensure Information Portal RE-5598764) and the Alt Adm was appointed the Alt Adm (Texas Unified Licensure Information Portal RE-5598765) on 11/10/2017. Record review of the Adm’s personnel record emailed to the surveyor on 02/07/2025 included three training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider A, dated 05/20/2022, 07/28/2023, and 08/30/2024. The three training certificates included outdated information regarding TAC Chapter 97.260(a) and the Department of Aging and Disability Services. The three training certificates read in part, “… Meets 40 TAC 97.260(a)… [Continuing Education Provider A] is an approved provider of continuing education training by Texas Department of Aging and Disability Services.” TAC Chapter 97 transferred to Chapter 558 as of 05/01/2019. The Department of Aging and Disability Services transferred to The Health and Human Services Commission effective 05/01/2019. The record included two training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider B, dated 11/30/2023 and 11/30/2024. Record review of the Alt Adm’s personnel record emailed to the surveyor on 02/07/2025 included five training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider A, dated 05/04/2020, 08/31/2021, 05/20/2022, 07/28/2023 and 08/30/2024. The five training certificates included outdated information regarding TAC Chapter 97.260(a) and the Department of Aging and Disability Services. The five training certificates read in part, “… Meets 40 TAC 97.260(a)… [Continuing Education Provider A] is an approved provider of continuing education training by Texas Department of Aging and Disability Services.” TAC Chapter 97 transferred to Chapter 558 as of 05/01/2019. The Department of Aging and Disability Services transferred to The Health and Human Services Commission effective 05/01/2019. The record included two training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider B, dated 11/30/2023 and 11/30/2024. During an interview with Continuing Education Provider A on 02/11/2025 at 2:30 PM, the surveyor informed Continuing Education Provider A that the surveyor had observed training certificates for the Adm and Alt Adm and wanted to confirm the authenticity of the training certificates. The surveyor informed Continuing Education Provider A that the certificates depicted Continuing Education Provider A issued: The Adm a training certificate for 12 Administrative hours, dated 05/20/2022; a training certificate for 12 Administrative hours, dated 07/28/2023; and a training certificate for 12 Administrative hours, dated 08/30/2024 and; The Alt Adm a training certificate for 12 Administrative hours, dated 05/04/2020; a training certificate for 12 Administrative hours, dated 08/31/2021; a training certificate for 12 Administrative hours, dated 05/20/2022; a training certificate for 12 Administrative hours, dated 07/28/2023; and a training certificate for 12 Administrative hours, dated 08/30/2024. Continuing Education Provider A confirmed that the Adm and Alt Adm had not completed any training, nor were issued training certificates for any of the provided dates. Continuing Education Provider A stated the Adm and Alt Adm had never completed any training with Continuing Education Provider A at any time. During an interview with Continuing Education Provider B on 02/11/2025 at 2:11 PM, the surveyor informed Continuing Education Provider B that the surveyor had observed training certificates for the Adm and Alt Adm and wanted to confirm the authenticity of the training certificates. The surveyor informed Continuing Education Provider B that the certificates depicted Continuing Education Provider B issued the Adm and Alt Adm a training certificate for 12 Administrative hours, dated 11/30/2023 and a training certificate for 12 Administrative hours, dated 11/30/2024. Continuing Education Provider B requested the surveyor text message Continuing Education Provider B the certificate dates and the name of the Adm and Alt Adm. The surveyor texted the information on 02/11/2025 at 2:26 PM. On 02/11/2025 between 2:38 PM and 2:40 PM, the surveyor received three pictures from Continuing Education Provider B that included the Adm and Alt Adm completed 12 hours of continuing education on 11/30/2022. During an interview with Continuing Education Provider B on 02/11/2025 at 2:41 PM, Continuing Education Provider B confirmed that the Adm and Alt Adm completed 12 continuing education hours on 11/30/2022 but no additional continuing education hours were ever completed by the Adm and Alt Adm with Continuing Education Provider B. Continuing Education Provider B stated she was angry the agency used her certificates fraudulently. The surveyor did not receive a training certificate for the Adm and Alt Adm from Continuing Education Provider B dated 11/30/2022. During an interview with the Adm on 02/12/2025 at 2:07 PM, the surveyor asked where the Adm and Alt Adm’s continuing education training certificates given to the surveyor came from and if the continuing education was done in-person or on-line. The Adm stated one of the companies used was Continuing Education Provider A and those trainings were done on-line but he thought the other trainings were in-person. The surveyor reviewed the above findings and asked the Adm to explain how the training certificates were obtained. The Adm stated he would have to call Continuing Education Provider A and B because he previously received emails from Continuing Education Provider A and B stating the trainings had been completed. The Adm stated he would call or email the surveyor after he made the phone calls. The surveyor stated names of the persons he spoke with were needed so the surveyor could verify the information. The surveyor received an email from the Adm on 02/13/2025 at 9:32 AM that included 6 attachments that read in part, “… I tried to get in contact with the company which offered the certificates based in Houston and could not get them. I was told by a friend who used them before they had moved locations. Below are updated certificates obtained from [Continuing Education Provider A]. Let me know if anything else is needed…” The 6 attachments in the email included 3 training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider A, for both the Adm and the Alt Adm dated 11/23/2023, 11/20/2024, and 02/12/2025. During an interview with Continuing Education Provider A on 02/14/2025 at 11:40 AM, the surveyor informed Continuing Education Provider A that the surveyor had observed training certificates for the Adm and Alt Adm and wanted to confirm the authenticity of the training certificates. The surveyor informed Continuing Education Provider A that the certificates depicted Continuing Education Provider A issued: Training certificates for 12 Administrative hours, dated 11/23/2023, 11/20/2024, and 02/12/2025. Continuing Education Provider A stated the training had not been completed with Continuing Education Provider A for any dates for the Adm and Alt Adm. Continuing Education Provider A stated online accounts had been set up by the agency, but no trainings had been done or completed. During a phone interview with the Adm on 02/14/2025 at 3:01 PM, the surveyor presented the above findings and asked if continuing education hours were completed on 11/23/2023, 11/20/2024 and 02/12/2025 with Continuing Education Provider A. The Adm stated he completed the continuing education hours listed on the Continuing Education Provider A certificates that were emailed to the surveyor. The Adm stated the certificates should be valid because the Adm and the Alt Adm completed the trainings. The surveyor requested a 3-way phone call between the Adm, the surveyor and Continuing Education Provider A to verify the information. The Adm stated he would let [Office Staff] handle the 3-way call. The surveyor ended the phone interview with the Adm on 02/14/2025 and heard Office Staff, located in the office next to the surveyors work area, on speakerphone with an unknown female regarding continuing education certificates. The surveyor entered Office Staff’s office and observed Office Staff on speakerphone. The surveyor asked who Office Staff was speaking with and Office Staff stated [Consultant]. The surveyor asked and received from Consultant her name, phone number and her employer. Consultant stated she worked for a consulting group who helped home health agencies and she was the consultant for [Agency]. Consultant stated she did not work for Continuing Education Provider A. Consultant further stated the 6 continuing education certificates for the Adm and Alt Adm dated 11/23/2023, 11/20/2024 and 02/12/2025 were valid and the continuing education hours were received from Continuing Education Provider A for the dates listed on the certificates. Consultant stated she sent the 6 certificates to the Adm. The surveyor presented the survey findings that Continuing Education Provider A reported continuing education hours had never been obtained by the Adm and Alt Adm from Continuing Education Provider A, that the 6 certificates were invalid and asked how Consultant obtained the 6 certificates. Consultant stated she did not know. The surveyor asked if the certificates were fabricated. Consultant put the 3-way call on hold and returned to the call approximately one minute later and stated Consultant falsified the 6 Continuing Education Provider A certificates for the Adm and Alt Adm for years 2023, 2025 and 2025 “to help them [Agency] out.” The surveyor asked to speak to Consultants manager and Consultant stated she was a manager at Consultant. Consultant further stated the Adm and Alt Adm missed continuing education hours since 2023 so she took it upon herself to create invalid certificates. During an interview with the Adm on 02/14/2025 at 3:26 PM, the surveyor presented the survey findings that the 6 continuing education certificates emailed to the surveyor on 02/13/2025 at 9:32 AM were fabricated and invalid and asked why the Adm stated he completed continuing education hours when he did not. The Adm stated he used Consultant for the continuing education hours and asked the surveyor why he would pay for something he would not use. The Adm stated he would have to deal with Consultant for saying the certificates were fabricated. The Adm stated he completed continuing education hours with Continuing Education Provider A. The surveyor offered a 3-way call between the Adm, the surveyor, and Continuing Education Provider A to verify the information. The Adm declined the 3-way call. During an interview with the Alt Adm on 02/12/2025 at 2:39 PM, the surveyor asked why continuing education training certificates given to the surveyor were invalid. The Alt Adm stated he did not know why, and he had completed continuing education training in 2022 but had not taken any continuing education training since 2022. Alt Adm stated he was unaware other continuing education training certificates existed, and he had not received additional training. The Alt Adm further stated he was unaware he needed to complete yearly continuing education training. During an interview with the Alt Adm on 02/14/2025 at 2:30 PM, the Alt Adm stated he did not take continuing education hours for the Alt Adm position, and he did not know anything about the fraudulent certificates given to the surveyor by the Adm. During a telephone interview with the Adm on 02/14/2025 at 3:16 pm, the Adm stated agency polices were not followed because they were things the agency overlooked. Agency policy titled, “Policy 1.45: CONTINUING EDUCATION FOR ADMINISTRATORS” undated, read in part, “… PURPOSE: To provide a process for recognizing and applying state regulatory requirements for a (sic) ongoing continuing education, and training for the administrator and management staff within the framework of administrative policy and procedures that: Develop and enhance employees' skills; Broaden and increase employee's knowledge base; Maintain and improve staff competency. POLICY: State regulatory requirements for continuing education are identified and applied within the context of administrative policy…” Agency policy titled, “Policy 1.21: AGENCY ADMINISTRATION” undated, read in part, “… POLICY: The Board of Directors shall appoint a full-time Administrator who shall have a full authority for management of Agency affairs… PROCEDURE: The Administrator shall have the overall authority and responsibility for agency operations… 2. Managing the Agency…” Agency policy titled, “Policy 1.4: MAINTENANCE OF POLICIES AND PROCEDURES” undated, read in part, “… PURPOSE: To ensure that the Agency policies and procedures are enforced. POLICY: All policies and procedures adopted… shall be enforced… PROCEDURE: 1. The Agency administrator is responsible for ensuring that all policies and procedures are enforced. 2. Any violation of the polices (sic) and procedures shall result in disciplinary action, suspension, termination, or reporting to the appropriate licensing authority as appropriate…”

A Recertification and Follow-up Survey entrance conference was conducted on 02/16/2022 at 11:50 AM with the Alt Adm. Census: LCHHS: 46 LHH: 0 PAS: 28 An exit conference was conducted on 02/25/2022 at 5:20 PM with the Alt Adm. The preliminary findings were discussed. The agency was found in compliance with 42 CFR Part 484.22 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A Recertification and Follow-up Survey entrance conference was conducted on 02/16/2022 at 11:50 AM with the Alt Adm. Census: LCHHS: 46 LHH: 0 PAS: 28 An exit conference was conducted on 02/25/2022 at 5:20 PM with the Alt Adm. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Deficiencies cited at standard level. ABBREVIATIONS % - percent Adm – Administrator Alt – Alternate AM - Ante meridiem Att - attendant AV - Arterio-venous BP – Blood Pressure CDC – Centers for Disease Control COVID-19 -Novel Coronavirus Disease of 2019 DON - Director of Nurses EMR: electronic medical record Etc- et cetera Gm – gram HF – heart failure HHA – Home Health Agency IV – intravenous IVPB -intravenous piggyback LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services LVN -Licensed Vocational Nurse Ml - milliliter OASIS- Outcome and Assessment Information Set PAS- Personal Assistance Services PICC - Peripherally Inserted Central Catheter PM - Post meridiem prn - as needed Pt – Patient POC - plan of care RN - registered nurse SASH - Saline, Administer infusion, Saline, Heparin Sic - grammatical error SN - skilled nurse Sol - solution

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: THIS IS A CONTINUING DEFICIENCY FROM SURVEY DATED 03/22/2019 CITED AT G0574. Based on record review and interview, the agency failed to ensure the POC include the types of supplies and equipment required; safety measures to protect against injury; patient treatments and patient-specific interventions and education in six of seven (Patient 1, 2 ,3, 4, 5 and 6) active records reviewed. Patient 1, 2, 3, 4, 5 and 6 POC’s did not include safety measures for paralysis/hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain), bleeding safety measures for a blood thinner medication, safety measures for a PICC line (a long IV line that is usually inserted in a smaller vein in the upper arm and ends in a larger vein in the chest near the heart), safety measures for wounds, patient specific interventions and education and IV supplies. These failures placed all agency patients at risk of not receiving interventions as needed and could result in declining health status. The failure to include safety measures for paralysis and/or hemiplegia on the POC resulted in Patient 1 and 2’s BP taken in the affected arm by the SN. Findings Include: Patient 1: Record review of the EMR included a POC dated 12/08/2021 to 02/05/2022 that read in part, “…Pt…with…left hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain)…” The EMR included a start of care SN assessment signed and dated by the DON on 12/08/2021 that read in part, “…Functional Abilities and Goals…Paralyzed Left Side Paralysis…Medical Necessity…left hemiplegia…” The POC did not include safety measures to ensure no BP’s were taken or blood draws performed on the left arm affected by paralysis/hemiplegia. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399466/pdf/postmedj00071-0039.pdf the blood pressure should always be measured in the unaffected arm in hemiplegic patients. The EMR included SN visit notes conducted by LVN on 12/16/2021, 12/23/2021, 12/30/2021 and 01/06/2022. The four LVN visit notes all indicated the BP was taken on the left side. During a telephone interview with the LVN on 02/24/2022 at 4:38 PM, the surveyor presented the above findings of why the BP was taken on the left side on a patient with paralysis/hemiplegia. The LVN stated he thought it was a documentation error. During a telephone interview with the DON on 02/25/2022 at 4:00 PM, the surveyor presented the above findings of why the POC did not include safety measures for paralysis/hemiplegia. The DON stated it was an oversight. The surveyor presented the above findings of how this failure could have impacted Patient 1. The DON stated hemiplegia was not very visible/noticeable in some patients but for patients that have a dialysis shunt, it would be something they really need to watch for. Patient 2: Record review of the EMR included a POC dated 11/30/2021 to 01/28/2022 that included a diagnosis of hypertensive heart disease with heart failure, hemiplegia affecting left side and the medication, Clopidogrel (a blood thinner used to prevent blood clots). The POC did not include safety measures to ensure no BP’s were taken or blood draws performed on the left arm affected by hemiplegia, and appropriate interventions for bleeding safety precautions for the blood thinner medication. According to https://www.mayoclinic.org, safety precautions while taking Clopidogrel include : Be careful when using a regular toothbrush, dental floss, or toothpick; be careful not to cut yourself when you are using sharp objects, such as a safety razor or fingernail or toenail cutters; avoid contact sports or other situations where bruising or injury could occur; check with your doctor right away if you notice any unusual bleeding or bruising, black, tarry stools, blood in the urine or stools, or pinpoint red spots on your skin. During a telephone interview with the DON on 02/25/2022 at 4:03 PM, the surveyor presented the above findings of why the POC did not include safety measures to ensure no BP’s were taken or blood draws were performed on the left arm affected by hemiplegia, and appropriate interventions for bleeding safety precautions for the blood thinner medication. The DON stated it was just an oversight. The surveyor presented the above findings of how this failure could have impacted Patient 2. The DON stated there are things easily missed by nurses if those things aren’t monitored. The DON stated they did not want the patient to end up in the hospital unnecessarily and that they really needed to keep a close watch on the patients so that didn’t happen. Patient 3: Record review of the EMR included a POC dated 11/30/2021 to 01/28/2022 that included a diagnosis of long term use of anticoagulants (medications that prevent the blood from clotting as quickly or effectively as normal) and the medication, Xarelto (a blood thinner used to prevent blood clots). The POC did not include appropriate interventions for bleeding safety precautions for the blood thinner medication. According to https://www.webmd.com//drugs/2/drug-156265-1969/xarelto-oral/rivaroxaban-2-5-mg-oral/details, safety precautions while taking Xalerto include: This medication may cause bleeding. Daily use of alcohol while using this medicine may increase your risk for stomach bleeding. Limit alcoholic beverages. Ask your doctor or pharmacist about how much alcohol you may safely drink. To lower the chance of getting cut, bruised, or injured, use great caution with sharp objects like safety razors and nail cutters. Use an electric razor when shaving and a soft toothbrush when brushing your teeth. Avoid activities such as contact sports. If you fall or injure yourself, especially if you hit your head, contact your doctor right away. Your doctor may need to check you for hidden bleeding that could be serious. During a telephone interview with the DON on 02/25/2022 at 4:05 PM, the surveyor presented the above findings of why the POC did not include appropriate interventions for bleeding safety precautions for the blood thinner medication. The DON stated it was just an oversight. The surveyor presented the above findings of how this failure could have impacted Patient 3. The DON stated the main aim of the home health nurses was making sure they do what is on the care plan to prevent the patient from going to the hospital since the nurses are the eyes for the patients. The DON stated if the nurse provided the care they are supposed to provide, they can prevent the patients from going to the hospital and from having complications. Patient 4: Record review of the EMR included a POC dated 12/08/2021 to 02/05/2022 that included a diagnosis of Type 2 Diabetes Mellitus and the medications Jentadueto (a medication used to control high blood sugar in people with type 2 diabetes) and Novolin injections twice daily (a type of insulin shot that works by lowering blood glucose levels in the blood). The POC include abnormal fasting blood sugar levels over 200 or less than 70 and random blood sugar levels over 250 or less than 70 to report to the physician. The POC did not include orders for the SN to monitor the blood sugar levels. The EMR included SN visit notes conducted by LVN on 12/15/2021, 12/22/2021, 12/29/2021, 01/05/2022. 01/12/2022, 01/19/2022 and 01/26/2022. Patient 4’s blood sugar was recorded on all seven SN visit notes. During a telephone interview with the LVN on 02/24/2022 at 4:40 PM, the surveyor presented the above findings of who performed the blood sugar check during the SN visits. The LVN stated the blood sugar was checked by the nurses. The surveyor presented the above findings of why the LVN checked the blood sugar levels when the POC did not include an order for the SN to monitor blood sugar levels. The LVN stated he thought there was an order on the POC for the SN to check the blood sugar, and the first time the agency had Patient 4 on service, the nurses checked the blood sugar. The LVN stated it should have been included on the POC. During a telephone interview with the DON on 02/25/2022 at 4:07 PM, the surveyor presented the above findings of why the POC did not include an order for the nurses to monitor the blood sugar levels. The DON stated that someone like Patient 4 monitors their own blood sugar and that is why it was not included on the POC. The surveyor presented the above findings of how this failure could have impacted Patient 4. The DON stated it was important for the home health nurse to check the patients blood sugar, even if the patient is also checking it, because sometimes the patient can end up in the hospital with high blood sugar. Patient 5: Record review of the EMR included a POC dated 11/25/2021 to 01/23/2022 that included a diagnosis of encounter for surgical aftercare following surgery on the skin and hypertensive heart disease with heart failure. The POC read in part, “…Allergies…Lisinipril (a medication used to treat high blood pressure), Sulfa…Medications…Ertapenem 1 Gram Sol In 50 Ml 0.9% Normal Saline Daily Intravenous via PICC line(an antibiotic that is administered through an IV used to treat severe infections caused by bacteria)… Heparin Lock Flush 100 Units/Ml 10 Ml as directed per SASH method daily Intravenous via PICC line… Sodium Chloride 0.9% 10ML IV Flush As Directed Per Sash Method Daily Intravenous Via PICC Line (SASH is an acronym [Saline, Administer infusion, Saline, Heparin] method to flush an IV catheter/PICC line when infusing medicine or fluids. Flushing with saline before and after you give an infusion rinses the catheter to prevent medicines from combining. Flushing with heparin at the end keeps the IV/PICC line from getting clogged)… SN to administer Cefepime 2 GM IV every 12 hours. Sodium Chloride 0.9% 10 ML flush used as directed, heparin 100 Unit/ML 5 ML flush used as directed. SN to perform double lumen PICC line catheter care with each IV medication administration. Use purple line for antibiotic infusion; flush with NS 5-20 ML as directed before and after each infusion followed by Heparin 100 unit/ML 5 ML as directed per SASH method. Flush unused (red) lumen once daily with NS 10 ML and Heparin 100 Unit/ML 5 ML…Skilled nursing to change PICC line dressing weekly and prn dislodgement. Cathflo (an IV/PICC line injectable clot-busting drug used when an IV line becomes blocked or occluded) as needed per protocol…Patient was admitted to…hospital with abcess (sic) in the buttocks area...While in the hospital, patient was treated for sepsis (the body’s extreme response to an infection and a life-threatening medical emergency that happens when an infection you already have triggers a chain reaction throughout your body) with IV antibiotics. Patient was discharged…with some changes in his medications. Patient has a covered dressing to the buttocks area, refused for RN to remove the dressing and states he changes dressings daily as needed and takes care of it himself…Patient was sent home with a left upper arm double lumen PICC line for at home daily IV antibiotics infusion. Patient was prescribed Ertapenem 1 gm IVPB once a day. Patient is unable to self administer antibiotics and safely take care of PICC line so SN will come in daily until 12/14/2021 to administer antibiotics as well as change PICC line dressing once a week and PRN…” The POC did not include: appropriate interventions for the SN to assess the PICC line site for signs and symptoms of infection and complications, safety measures for the PICC line; IV/PICC line supplies; orders for changing injection caps on the PICC line ports; the type of dressing change and steps for the SN to perform when changing the PICC line site dressing; interventions to minimize the risk of anaphylaxis or other adverse reactions while receiving IV therapy; the rate of infusion for the IV medication; how the IV medication was to be infused (pump, etc); a complete medication list to include medications used to treat adverse reactions and anaphylactic reactions to the IV medications with frequency of administration; instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred when SN not present; the type(s) of medication allergens including the types of reactions to the allergens; safety measures for the wound; and appropriate interventions for the SN to assess for HF signs and symptoms with abnormal parameters to report to the physician. During a telephone interview with the DON on 02/25/2022 at 4:11 PM, the surveyor presented the above findings of why the POC did not include IV/PICC line supplies, safety measures for the PICC line, safety measures for the wound, orders for changing injection caps on the PICC line ports, the type of dressing change (sterile or aseptic), steps for the SN to perform when changing the PICC line site dressing and appropriate interventions for the SN to assess for HF signs and symptoms with abnormal parameters to report to the physician. The DON stated she included these things on the POC and that the IV antibiotic came in a pack to infuse via gravity infusion and did not require a pump. The DON stated the POC included orders for the SN to change the PICC line dressing. The surveyor reviewed the order on the POC for the PICC line dressing change with the DON that read, “Skilled nursing to change PICC line dressing weekly and prn dislodgement” and presented the above findings of why the order did not include the type of dressing change (sterile or aseptic) and the steps to perform when changing the dressing. The DON stated she did not include the steps for the dressing change because she didn’t know that needed to be included. The DON stated the other missing items on the POC were just an oversight on her part. The surveyor presented the above findings of why the POC did not include the type(s) of medication allergens including the types of reactions to the allergens. The DON stated it was an oversight. The surveyor presented the above findings of why the POC included two different IV medication orders: Ertapenum 1 gm IV daily and Cefepime 2 gm IV every 12 hours. The DON stated she did not know why the POC included two different IV medications but the correct medication was Ertapenum and Cefepime should not be on the POC. The surveyor presented the above findings of why the POC did not include orders for the SN to assess the PICC line site for signs and symptoms of infection and complications, interventions to minimize the risk of anaphylaxis or other adverse reactions while receiving IV therapy and how the IV medication was to be infused (pump, etc). The DON stated she thought all these items were included on the POC. The DON reviewed the POC and stated she didn’t see any of those things on the POC and it was an oversight. The surveyor presented the above findings of why the POC did not include a complete medication list to include medications used to treat adverse reactions and anaphylactic reactions to the IV medications with frequency of administration. The DON stated medications for adverse and anaphylactic reactions were not available in Patient 5’s home. The surveyor presented the above findings of what the SN would do if an adverse or anaphylactic reaction occurred during the IV infusion. The DON stated that was something she had not thought about but, in the future, she would call the doctor and get orders for that. The surveyor presented the above findings of why the POC did not include instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred when SN not present. The DON stated it was an oversight. The surveyor presented the above findings of how these failures could have impacted Patient 5. The DON stated it could have led to missing things, for example if the PICC line got infected and Patient 5 did not know what to do about the infection, or if the dressing came off and Patient 5 would not know what to do, so these things were not good for the patient. Patient 6: Record review of the EMR included a POC dated 12/04/2021 to 02/01/2022 that included a diagnosis of end stage renal disease and dependence on renal dialysis and the medication Clopidogrel. The POC read in part, “…kidney dialysis three times a week...SN as assess AV shunt (a surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body) every visit…including signs and symptoms of infection…Has AV fistula graft on left upper arm for dialysis treatment...” The POC did not include bleeding precautions due to the blood thinner, Clopidogrel; safety measures for the AV shunt, the nephrologist (a kidney doctor) name and the dialysis clinic. During a telephone interview with the DON on 02/25/2022 at 4:26 PM, the surveyor presented the above findings of why the POC did not include bleeding precautions due to the blood thinner, Clopidogrel; safety measures for the AV shunt, nephrologist name and the dialysis clinic. The DON stated she thought the dialysis clinic was listed on the OASIS SN assessment but was not on the POC. The surveyor presented the above findings of how these failures could have impacted Patient 6. The DON stated it would help to coordinate care with all agencies involved since the goal was to prevent hospitalizations and when care is not coordinated, the patient could end up in the hospital unnecessarily.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to integrate services with all providers and to enforce their written policy regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of patient services among the agency and other providers of health care services involved in the care of a patient, who were known to the agency to have other providers. In one of one (Patient 6) record reviewed who received LCHHS and PAS services from the agency, the agency failed to coordinate care between the agency LHCCS and PAS providers, the nephrologist and the dialysis clinic. These failures placed the agency patients at risk of harm when the agency’s staff failed to coordinate services with all providers, due to the lack of shared information regarding the ongoing care, and changes in service needs of the patients. Findings Include: Agency policy titled, "POLICY 1.4 MAINTENANCE OF POLICIES AND PROCEDURES" read in part, "...PURPOSE: To ensure that the Agency policies and procedures are enforced. POLICY: All policies and procedures by HHA shall be enforced. PROCEDURE: 1. The agency administrator is responsible for ensuring that all policies and procedures are enforced..." Agency policy titled, "Policy 4.18 Coordination of Services", read in part “…All skilled clinicians and unskilled personnel furnishing care maintain liaison to ensure that client services are coordinated effectively and in accordance with the objectives outlined in the plan of care...Primary Care Coordinator: 12. In an effort to provide coordinated services with the client, family and all other clinicians a designated professional is assigned to each client that is responsible for coordination of services among various disciplines to support the goals outlined in the plan of care and to achieve client outcomes…14. Indicated responsibilities of the care coordinator are as follows (not an inclusive list): a. Communicating with all personnel caring for the client including the physician..." The surveyor reviewed the active LCHHS and PAS patient list provided by the agency which included Patient 6 as an active patient receiving both LCHHS and PAS services from the agency. The agency active employee list included the DON was hired as the DON on 07/06/2017. Patient 6: Record review of the LCHHS EMR included a POC dated 12/04/2021 to 02/01/2022 that included an order for the SN to visit the patient one time a week for nine weeks plus two prn visits. The POC included a diagnosis of dependence on renal dialysis. The POC read in part, “…kidney dialysis three times a week (a process in which blood is removed from the body, cleansed and then returned to the body)…Has AV fistula graft on left upper arm for dialysis treatment...” The POC did not include the PAS provider, services provided by the PAS provider, the name of the nephrologist (a kidney doctor) and the dialysis clinic. The record included no evidence that coordination of services had occurred between the LCHHS agency staff and the PAS agency staff, the nephrologist and the dialysis clinic. Record review of the PAS record included an individualized service plan dated 09/23/2021 that included 23 hours per week of PAS services with an initiation date of 09/23/2021. The surveyor reviewed a document titled, “Member Visit Log” that indicated 203 hours of PAS services were provided by Att from 12/06/2021 to 02/07/2022. The record included no evidence that coordination of services had occurred between the LCHHS agency staff and the PAS agency staff, the nephrologist and the dialysis clinic. During a telephone interview with the DON on 02/25/2022 at 4:27 PM, the surveyor presented the above findings of why the agency failed to coordinate care between the LCHHS agency staff, the PAS agency staff, the nephrologist and the dialysis clinic. The DON stated there was no coordination of care between LCHHS, PAS, the nephrologist and the dialysis clinic. The DON stated during the SN recertification visit, the DON asked Patient 6 if she was having any problems with dialysis and Patient 6 stated, “No.” The DON stated she thought the name of the dialysis clinic was listed on the OASIS SN assessment but was not on the POC. The surveyor presented the findings of the previous agency survey dated 03/22/2019 that resulted in an agency violation for failure to coordinate services among the agency and other providers involved in the care of a patient and why the agency did not implement its written plan of correction following the 03/22/2019 survey and why the issue still occurred. The DON stated she did not remember. The surveyor presented the above findings of how these failures could have impacted Patient 6. The DON stated it would help to coordinate care with all agencies involved since the goal was to prevent hospitalizations and when care is not coordinated, the patient could end up in the hospital unnecessarily.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases to include COVID-19. The agency failed to develop a plan for the appropriate actions that are expected to result in improvement and disease prevention specific to care and services providing in the home setting. This failure placed agency patients and household members and agency staff at increased risk of transmitting and contracting the COVID-19 infection. Findings Include: The surveyor requested all agency policy and procedures, infection control records, and COVID-19 information during the entrance conference on 02/16/2022. Review of the agency policy and procedures provided by the agency revealed no updates to the infection control program to include COVID-19 and no COVID-19 policies for the agency. Agency policy titled, "POLICY 1.4 MAINTENANCE OF POLICIES AND PROCEDURES" read in part, "...PURPOSE: To ensure that the Agency policies and procedures are enforced. POLICY: All policies and procedures by HHA shall be enforced. PROCEDURE: 1. The agency administrator is responsible for ensuring that all policies and procedures are enforced...4. The Agency policies are...updated at least once yearly and as needed..." Agency policy titled, “POLICY 4.50 INFECTION CONTROL COMMUNICABLE AND REPORTABLE DISEASES” read in part, “…PURPOSE: Healthcare providers in the United States are required to report disease, conditions or outbreaks as determined by local, state or territorial law and regulation, and as outlined in the state’s list of reportable conditions…” A three page document located after policy 4.50 was titled, “NATIONALLY NOTIFIABLE INFECTIOUS DISEASES UNITED STATES 2008”. The three page document included a list of infectious diseases in 2008 that were to be reported by the agency to the state. The list did not include COVID-19. The three page document read in part, “…REFERENCE: CDC…United States, 2008…” During an interview with the Alt Adm on 02/25/2022 at 3:22 PM, the surveyor presented the above findings of why the agency failed to adopt and enforce written policies addressing infection control to include the prevention of the spread of the infectious and communicable disease COVID-19 and why the agency had not updated the list in the policy manual titled, “NATIONALLY NOTIFIABLE INFECTIOUS DISEASES UNITED STATED 2008” since 2008 to include COVID-19. The Alt Adm stated the agency asked their consultant, who provides the agency with their policies, where their COVID policies were and the consultant stated when the consultant finished writing the COVID policies, they would send copies to the agency, but they had not finished them yet. The Alt Adm stated when the consultant was contacted by the agency after the entrance conference, the consultant told the agency the COVID policies would be ready before the survey was over, but they still weren’t ready. The surveyor presented the above findings of why it had taken almost two years for the consultant to provide the agency with COVID policies and updated policies on infection control. The Alt Adm stated he did not know. The surveyor presented the above findings of how this failure could affect the agency staff, patients and household members of the patients. The Alt Adm stated the agency had already trained employees to always use mask and gloves and the staff were doing COVID screenings. The Alt Adm stated when the COVID policies were available to the agency, the agency would give them to the employees so they would know the standards in home health. The Alt Adm stated he would go get the COVID policies next week. Agency policy titled, “POLICY 4.47: INFECTION CONTROL PROGRAM” read in part, “…PURPOSE: To reduce the risk of acquired transmitted infections among…patients and staff through a formalized, coordinated process to reduce those risks…DEFINITIONS…Epidemic Infection: A higher than expected level of infection by a common agent in a defined population during a defined period…POLICY…HHA has established a comprehensive Infection Control Program to ensure that there is a functioning coordinated process in place, to reduce the risks of acquired and transmitted infections among patients and staff, and to organize the use of resources…HHA infection control program is a systematic and coordinated process designed to incorporate the following information: Current scientific methods and epidemiologic principles for infection surveillance and prevention…Recognized practice guidelines such as those published by the Centers for Disease Control and Prevention…Communicable Disease Prevention and Control Act, Health and Safety Code…and State List of Notifiable Conditions List (updated annually)…”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the SN’s failed to ensure clinical notes were written as required in six of seven active records reviewed (Patient 1, 2, 3, 4, 6 and 7) who received skilled services. This failure placed the agency patients at risk of not receiving the appropriate care and services due to their current health status not being incorporated into the records. Findings include: During an interview with the Alt Adm on 02/16/2022 at 11:50 AM, the Alt Adm stated the agency used both an EMR and paper records for patient records. Patient 1: Record review of the EMR on 02/17/2022 included a POC dated 12/08/2021 to 02/05/2022. The POC included an order for the SN to visit the patient one time a week for nine weeks plus two prn visits. The record included seven incomplete SN visit notes for visits conducted by LVN on: 12/16/2021, 12/23/2021, 12/30/2021, 01/06/2022, 01/13/2022, 01/20/2022 and 01/27/2022. The seven visit notes were not electronically signed or dated by LVN. Patient 2: Record review of the EMR on 02/17/2022 included a POC dated 11/30/2021 to 01/28/2022. The POC included an order for the SN to visit the patient one time a week for nine weeks plus two prn visits. The record included seven incomplete SN visit notes for visits conducted by LVN on: 12/11/2021, 12/18/2021, 12/23/2021, 12/30/2021, 01/08/2022, 01/15/2022 and 01/22/2022. The seven visit notes were not electronically signed or dated by LVN. The SN visit note dated 01/22/2022 included: Patient 2’s name, the type of SN visit was checked as education and/or training, primary and secondary diagnosis and LVN’s name. The rest of the note was blank and incomplete. Patient 3: Record review of the EMR on 02/17/2022 included a POC dated 11/30/2021 to 01/28/2022. The POC included an order for the SN to visit the patient one time a week for nine weeks plus two prn visits. The record included seven incomplete SN visit notes for visits conducted by LVN on: 12/11/2021, 12/18/2021, 12/23/2021, 12/30/2021, 01/08/2022, 01/15/2022 and 01/22/2022. The seven visit notes were not electronically signed or dated by LVN. Patient 4: Record review of the EMR on 02/17/2022 included a POC dated 12/08/2021 to 02/05/2022. The POC included an order for the SN to visit the patient one time a week for nine weeks plus two prn visits. The record included seven incomplete SN visit notes for visits conducted by LVN on: 12/15/2021, 12/22/2021, 12/29/2021, 01/05/2022, 01/12/2022, 01/19/2022 and 01/26/2022. The seven visit notes were not electronically signed or dated by LVN. Patient 6: Record review of the EMR on 02/17/2022 included a POC dated 12/04/2021 to 02/01/2022. The POC included an order for the SN to visit the patient one time a week for nine weeks plus two prn visits. The record included seven incomplete SN visit notes for visits conducted by LVN on: 12/18/2021, 12/23/2021, 12/30/2021, 01/08/2022, 01/15/2022, 01/22/2022 and 01/29/2022. The seven visit notes were not electronically signed or dated by LVN. Patient 7: Record review of the EMR on 02/17/2022 included a POC dated 11/28/2021 to 01/26/2022. The POC included an order for the SN to visit the patient one time a week for nine weeks plus two prn visits. The record included eight incomplete SN visit notes for visits conducted by LVN on: 11/30/2021, 12/07/2021, 12/14/2021, 12/21/2022, 12/28/2021, 01/04/2022, 01/11/2022 and 01/18/2022. The eight visit notes were not electronically signed or dated by LVN. During a telephone interview with the LVN on 02/24/2022 at 4:34 PM, the surveyor presented the above findings of when visit notes are completed following SN visits. The LVN stated the week the visit was made. The surveyor reviewed the dates of the incomplete SN visit notes for Client 1, 2, 3, 4, 6 and 7 and presented the above findings of why the SN visit notes were not completed. The LVN stated it was probably due to his getting behind. During a telephone interview with the DON on 02/25/2022 at 3:35 PM, the surveyor presented the above findings of when visit notes are completed following SN visits. The DON stated the expectation was visit notes should be completed within 48 hours from the visit, but sometimes it did not happen that way because the nurses might be running behind. The surveyor presented the above findings of how this failure could have impacted the patients. The DON stated the nurse might not remember what the patient’s condition was during the visit if documentation was done late. Agency policy titled "Policy 4.32: CLINICAL RECORDS DOCUMENTATION", read in part, "...Procedures: 3. All…staff are to sign their name, professional title, and date when making entries into the clinical record, unless it is indicated that initials are appropriate...6. Visit notes are to be submitted with appropriate time sheets on Monday, Wednesday and Friday at the minimum (example: visits made on Monday are to be turned in on following Wednesday) unless otherwise informed by supervisor...10. Entries are to be made using the following guidelines: F. Visit notes, progress notes, orders, communication etc...are to be placed in clinical record within 14 days of occurrence..." Agency policy titled, "POLICY 1.4 MAINTENANCE OF POLICIES AND PROCEDURES" read in part, "...PURPOSE: To ensure that the Agency policies and procedures are enforced. POLICY: All policies and procedures by HHA shall be enforced. PROCEDURE: 1. The agency administrator is responsible for ensuring that all policies and procedures are enforced..."