Every finding on record at Reliant Home Healthcare Services

The following reflects the findings of the California Department of Public Health during a recertification survey conducted July 25, 2023, through July 31, 2023. Representing the Department: Surveyor 45388 Surveyor 46917 Census: 26 Unduplicated Admissions: 70 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met. No deficiencies were cited for Emergency Preparedness.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted July 25, 2023, through July 31, 2023. Representing the Department: Surveyor 45388 Surveyor 46917 Census: 26 Unduplicated Admissions: 70 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met. Five deficiencies were cited for this recertification survey.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure services outlined on the plan of care (POC- provides direction of the type of care a patient needs and the ways of meeting them) was provided for four of seven sampled patients (Patients 1, 2, 3, and 5) when: 1. Patient 1 did not receive Certified Home Health Aide (CHHA) home visit from May 4, 2023, to July 2, 2023. (The POC indicated CHHA visits were to be provided three to five times a week.) 2. Patient 3 was missing 68 hours of RN (Registered Nurse) and LVN (Licensed Vocational Nurse) home visits for the month of June 2023. (The POC indicated Patient 2 was to be provided 368 hours of RN and LVN home visits per month. Patient 2 received 300 hours of RN and LVN home visits, instead of 368.) 3. Patient 3 was missing 14 CHHA home visits from June 4, 2023, through July 28, 2023. (The POC indicated Patient 2 was to be provided three CHHA home visits per week. Patient 3 should have received 24 CHHA home visits, instead of 10.) 4. Patient 5 was missing two hours of RN Supervisory home visit for two consecutive months. (The POC indicated Patient 5 was to be provided two hours of RN Supervisory home visit.) These failures had the potential for Patients 1, 2, 3, and 5 not to receive adequate care to meet their medical and personal needs. Findings: 1. A review of Patient 1’s clinical record, the “face sheet (contains demographic and medical information)” indicated Patient 1 had a start of care date of May 4, 2023, with a certification period (dates of when the patient receives benefits) of July 3, 2023, through August 31, 2023. Further review indicated Patient 1 had diagnoses of quadriplegia (unable to move both arms and legs), pressure ulcer (an injury that breaks down the skin and underlying tissue), and pain disorder. A review of Patient 1’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE (HHCPOC- document containing a patient’s POC),” dated certification period (the period of time a patient receives care) of May 4, 2023, through July 2, 2023, indicated CHHA home visits were to be provided to the patient three to five times a week for bathing and all activities of daily living. During a concurrent interview and record review, with the Director of Patient Care Services Designee (DPCSD) and the Director of Patient Care Services (DPCS), on July 28, 2023, at 12:25 PM, the DPCSD and DPC reviewed Patient 1’s CHHA visit notes, which indicated Patient 1 was not provided CHHA home visits between May 4, 2023, through June 24, 2023 (Approximately 12 to 20 missed CHHA visits). The DPCSD stated there should have been at least three to five home visits during the certification period of May 4, 2023, through July 2, 2023, as specified in Patient 1’s HHPOC. The DPCSD further stated there were no CHHA home visit notes found, and therefore there were no proof the CHHA home visits were provided. 2. A review of patient 2’s clinical record, the “face sheet,” indicated Patient 2 had a start of care date of June 26, 2017, with a certification period of May 26, 2023 to July 24, 2023. Further review indicated Patient 2 had diagnoses of acute and chronic respiratory failure with hypoxia (not get enough oxygen to the body), obstructive sleep apnea (episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen), and epilepsy (a nerve disorder which can causes uncontrolled body movements and loss of level of consciousness). A review of Patient 2’s “HHCPOC,” dated certification period of May 26, 2023, through July 24, 2023, indicated Patient 1 was to be provided by 360 hours of Licensed Vocation Nurse (LVN) home visits per month and 8 hours of Registered Nursing home visits per month. (Totaling to 368 hours of LVN and RN home visits per month.) During a concurrent interview and record review, on July 28, 2023, at 12:35 PM, with the DPCSD, the DPCSD reviewed Patient 2’s RN and LVN home visit notes, which indicated Patient 2 was provided 300 hours of RN home visits for the month of June 2023. Further review indicated there were no LVN home visits that was provided. The DPCSD stated Patient 2 was not provided LVN home visits but was provided RN home visits instead, because it was based on the available staff that the agency had. The DPCSD acknowledged Patient 2 should have been provided a total of 360 hours of LVN home visit and 8 hours of RN home visit, totaling to 368 hours per month, instead of 300 hours of RN home visit. The DPCSD further stated Patient 2 was missing 68 hours for the month of June 2023. 3. A review of Patient 3’s clinical record, “face sheet,” indicated Patient 3 had a start of care date of April 3, 2023, with a certification period of June 2, 2023, through July 31, 2023. Further review indicated Patient 3 had diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes (high blood sugar levels), and dysphagia (difficulty swallowing). A review of Patient 3’s “HHCPOC,” dated certification period of June 2, 2023, through July 31, 2023, indicated CHHA visits were to be provided to the patient 3 times a week. During a concurrent interview and record review, on July 31, 2023, at 10:43 AM, with the DPCSD, the DPCSD/AD reviewed and acknowledged Patient 3’s CHHA home visits from June 4, 2023, through July 28, 2023, which indicated Patient 3 had missing CHHA home visits on the following weeks: a. June 4, 2023, to June 10, 2023: CHHA home visit conducted on June 6, 2023 (Two missed visits) b. Junes 11, 2023, to June 17, 2023: CHHA home visit conducted on June 11, 2023. (Two missed visits) c. June 18, 2023, to June 24, 2023: CHHA home visit conducted on June 19, 2023. (Two missed visits) d. June 25,2023, to July 1, 2023: No CHHA home visits (Three missed visits) e. July 2, 2023, to July 8, 2023: CHHA home visit conducted on June 8, 2023. (Two visits missed) f. July 9, 2023, to July 15, 2023: CHHA home visit conducted on July 12, 2023, and July 15, 2023. (One missed visit) g. July 16, 2023, to July 22, 2023: CHHA home visit conducted on July 19, 2023, and July 22, 2023. (One missed visit) h. July 23, 2023, to July 28, 2023: CHHA home visit conducted on July 24, 2023, and July 26, 2023. (One missed visit) During an interview on July 31, 2023, at 10:46 AM, with the DPCSD, the DPCSD stated Patient 3 should have been provided CHHA home visits three times a week and was not sure why Patient 3 had 14 missed home visits. 4. A review of Patient 5’s clinical record, “face sheet,” indicated Patient 5 had a start of care date of November 7, 2019, with a certification period of April 20, 2023, through June 18, 2023. Further review indicated Patient 5 had diagnoses of end stage renal disease (kidneys no longer filter and work) and polycystic kidney (kidneys having a lot of fluid filled sacs), A review of Patient 5’s “HHCPOC,” dated certification period of April 20, 2023, through June 18, 2023, indicated Patient 5 was to be provided two hours of RN Supervisory home visit per month. During a concurrent interview and record review, on July 31, 2023, at 10:54 AM, with the DPCSD, the DPCSD reviewed the RN Sup visit notes for the certification period of April 20, 2023, through June 18, 2023, and stated there were no RN Sup visits provided. (Two hours of RN Supervisory home visit missed for two consecutive months.) The DPCSD further stated the RN Sup should have provided the 2 hours of RN Supervisory home visit to Patient 5. The DPCSD/AD stated she did not know why it was not done. During a concurrent interview and record review on July 31, 2023, at 2:40 PM, with the DPCSD, the DPCSD reviewed the agency’s undated P&P titled, “Plan of care- CMS# 485 and Physician Orders,” which indicated “Plan of care- CMS# 485” indicated, “Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long range needs and resources…3.Each patient must receive home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed (every 60 days or more frequently when indicated by changes in the patient’s condition) and signed by a doctor of medicine, osteopathy or podiatry acting within the scope of his or her state license, certification or registration…5. All patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all Agency staff are working from a current plan…the plan of care is updated to reflect all current ongoing orders including any verbal orders received during the 60-day period… 22. Verbal orders are accepted only by personnel authorized to do so by applicable state laws and regulations and Agency policy. Verbal orders are put in writing, signed, timed and dated with the date of receipt by a RN…It is the RN’s or therapist’s responsibility to make any necessary revisions to the Plan of Care based on that order (s).23. Orders are verified when: There are questions or discrepancies with orders. A person taking a verbal order is not qualified to review the order for appropriateness…25. All clinical services are implemented only in accordance with a Plan of Care established by a physician’s written order…”. The DPCSD/AD stated the policy was not followed for Patients 1, 2, 3, and 5 and stated it should have been followed because it is important for the continuity of care and to make sure the patient is getting the accurate care orders.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a medication reconciliation (the process of reviewing a patient’s medication orders to all the medications that the patient has been taking) was conducted on an ongoing basis and implemented in accordance with the agency’s policy and procedure (P&P) for three of seven sampled patients (Patients 1, 2, and 3) when: 1. For Patient 1, eight of her home medications did not match the Medication Profile (MP- written summary of all the medications ordered by the physician for the patient to receive). 2. For Patient 2, one of his home medications did not match the MP. 3. For Patient 3, four of his home medications that did not match the MP. These failures had the potential to cause ineffective drug therapy, significant side effects, and noncompliance with drug therapy to Patients 1, 2, and 3, which could place their health and safety in harm. Findings: 1. A review of Patient 1’s clinical record, the face sheet (contains demographic and medical information) indicated Patient 1 had a start of care date of May 4, 2023, with a certification period (dates of when the patient receives benefits) of July 3, 2023, through August 31, 2023. Patient 1 had diagnoses of quadriplegia (unable to move both arms and legs), pressure ulcer (an injury that breaks down the skin and underlying tissue), and pain disorder. During a concurrent interview and record review, on July 26, 2023, at 6:50 PM, with the Director of Patient Care Services Designee (DPCSD) and the Director of Patient Care Services (DPCS), the DPCSD and the DPCS stated the MP they have provided for Patient 1 was the most current, and it should match her home medications. During a home visit on July 27,2023, at 8:35 AM, with Certified Home Health Aide (CHHA 1) and Licensed Vocational Nurse (LVN 1), Patient 1 was laying on a hospital bed, in the living room, with Patient 1’s husband (PT1H) next to her, feeding her dry toast. During a concurrent observation, interview, and record review, on July 27, 2023, at 8:45 AM, with PT1H and LVN 1, Patient 1’s home medications, which were all in a plastic container, on a small table in the living room, were inspected and compared with the MP. The following medications had discrepancies: a. Baclofen (medication used to relax muscles) 10 mg (milligram- unit of measurement) tablet one tablet once daily, which was the home medication, did not match the MP, which indicated an order of Baclofen 10 mg tablet 10 tabs (Total dose of 100 mg) once daily. (A difference in dosage.) b. Dilaudid (medication used to treat severe pain) 4 mg one tablet five times a day (Total dose of 20 mg daily), which was the home medication, did not match the MP, which indicated an order of Dilaudid 4 mg tablet 4 tab (16 mg) every 6 hours (Total dose of 96 mg) as needed. (A difference in dosage.) c. Effexor (medication used to help lessen anxiety) 75 mg capsule daily and Effexor 150 mg cap daily (Total dose of 225 mg), which was the home medication, did not match the MP, which indicated an order for Effexor 150 mg once daily (75 mg less than what Patient 1 is taking). (A difference in dosage.) d. Gabapentin (medication used for nerve pain) 300 mg tablet 2 tablets (600 mg) by mouth three times a day (Total dose of 1800 mg), which was the home medication, did not match the MP, which indicated an order for Gabapentin 100 mg tablet 200 tablets once daily (Total dose of 20,000 mg). (A difference in dosage.) e. Lidocaine (medication used for pain) 5 % (percent) transdermal (through the skin) two patches topically to skin every morning (Total dose of 10 %), which was the home medication, did not match the MP, which indicated an order for Lidocaine 5% transdermal patch 5% film ER (Extended release- a drug delivery system in the form of a film on the skin that releases the drug over an extended period of time) change every 24 hours (Total dose of 5%). (A difference in dosage.) f. Naloxone (medication to reverse pain medication overdose) 4 mg/ 0.1 ml (milliliters- unit of measurement) liquid 1 spray 1 nostril once, may repeat in 2 to 3 minutes in other nostril if needed, which was the home medication, did not match the MP, which indicated an order for Naloxone 4mg/ 0.1 ml nasal spray dosage 4 spray as needed. (A difference in dosage.) g. Famotidine (medication used to lower acid in the stomach) 40 mg 1 tablet a day (total dose of 40 mg), which was the home medication, did not match the MP, which indicated an order for Pepcid 20 mg tablet 20 tablets (total dose of 400 mg) once daily. (A difference in dosage.) h. Methocarbamol (medication used to relax muscles) 750 mg by mouth 4 times daily as needed (Total dose up to 3000 mg), which was the home medication, did not match the MP, which indicated an order for Methocarbamol 750 mg tablet three times a day (Total daily dose of 2250 mg). (A difference in dosage.) During an interview on July 27, 2023, at 9:30 AM, with LVN 1, LVN 1 stated the expectation was for the MP to match what Patient 1 was taking at home. LVN 1 further stated the MP was supposed to be checked for accuracy every time a visit was made, and if there were any changes, the MP was supposed to be verified with the physician and updated. LVN 1 stated it was important to reconcile the medication for the safety of the patient and to make sure the patient was getting the correct medication. 2. A review of Patient 2’s clinical record, the face sheet indicated Patient 2 had a start of care date of June 26, 2017, with a certification period of May 26, 2023 through July 24, 2023. Patient 2 had diagnoses of acute and chronic respiratory failure with hypoxia (not get enough oxygen to the body), obstructive sleep apnea (episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen), and epilepsy (a nerve disorder which can causes uncontrolled body movements and loss of level of consciousness). During a concurrent interview and record review, on July 26, 2023, at 6:55 PM, with the DPCSD and the DPCS, the DPCSD and the DPCS stated the MP they have provided for Patient 2 was the most current and stated it should match his home medications. During a home visit on June 27,2023, at 11:12 AM, with the DPCSD/AD, Patient 2 was sitting on the couch, in the living room, watching television. During a concurrent observation, interview, and record review, on July 27, 2023, at 11:43 AM, with Patient 2’s Mother (PT2M) and the DPCSD, Patient 2’s home medications, which were all in Patient 2’s room, were inspected and were compared with the MP. Upon inspection, it was noted that Cetirizine (medication used to treat allergies) 10 mg chew and swallow 1 tab daily (Total dose of 10 mg) was the home medication did not match the MP. The MP indicated an order for Cetirizine Chewable 5 mg Oral Daily (Total dose of 5 mg). (A different in dosage.) During an interview on July 27, 2023, at 11:48 AM, with the DCPSD, the DPCSD stated Patient 2’s current MP did not match what Patient 2 was currently taking at home. The DPCSD further stated whenever there is a LVN or Registered Nurse (RN) that comes to do a visit, the MP is supposed to be checked against what the patient is currently taking and any changes has to be told to the physician and documented. The DPCSD stated it was important for the MP to match what the patient is taking because of the safety of the patient. 3. A review of Patient 3’s clinical record, the face sheet indicated Patient 3 had a start of care date of April 3, 2023, with a certification period of June 2, 2023, through July 31, 2023. Patient 3 had diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes (high blood sugar levels), and dysphagia (difficulty swallowing). During a concurrent interview and record review, on July 27, 2023, at 12:08 PM, with the DPCSD, the DPCSD stated the MP they have provided for Patient 3 was the most current, accurate medications, and that it should match his home medications. During a home visit on July 27,2023, at 12:32 PM, with Patient 3’s Sister (PT3S) and LVN 2, Patient 3 was sitting in a wheelchair, in a living room. During a concurrent observation, interview, and record review, on July 27, 2023, at 12:46 PM, with PT3S and LVN 2, Patient 3’s home medications, which were all on the living room table, were inspected and compared with the MP. The following medications had discrepancies: a. Calcium 500- Vitamin D 3 (supplements) 10 mcg (micrograms- unit of measurement) 1 tablet daily, which was the home medication, did not match the MP. (There was no order for Calcium 500- Vitamin D 3 supplement.) b. Sertraline (medication used to treat anxiety, depression, panic attacks) 25 mg 1 tablet daily, which was the home medication, did not match the MP. (There was no order for Sertraline medication.) c. Oxiconazole Nitrate (medication used to treat skin infections) 1% cream 1 gram (g- unit of measurement) in the affected zone twice a day, which as the home medication, did not match the MP. (There was no order for Oxiconazole Nitrate 1% cream.) d. Polyethylene Glycol 3350 (medication used to treat constipation) mix and drink one packet by mouth in the morning, which was the home medication, did not match the MP. (There was no order for Polyethylene Glycol. During an interview on July 27, 2023, at 1:05 PM, with LVN 2, LVN 2 each patient’s MP is supposed to be the same as the medication that patient is taking. LVN 2 acknowledged Patient 3’s medication did not match the current MP and stated it should have so that the staff that come in know what medications the patient is taking. During a concurrent interview and record review on July 28, 2023, at 10:25 AM, with the DPCSD, the DPCSD reviewed the agency’s undated policy and procedure (P&P) titled “Medication Reconciliation”, which indicated, “…At the time of admission, the admitting RN (Registered Nurse), PT (Physical Therapist), or SLP (Speech Pathologist) will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. Any concerns or discrepancies will be reconciled by a RN with the patient’s physician. Discrepancies includes duplications, omissions, changes, contraindications and/or unclear information…2. Medications orders while the patient is receiving care will be compared to the medication list/ profile. The medication list/ profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated…”. The DPCSD stated the policy was not followed and should have been followed.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care (POC- provides direction of the type of care a patient needs and the ways of meeting them) reflected the physician’s orders for four of seven sampled patients (Patients 1, 2, 4, and 5) when: 1. For Patient 1, the Certified Home Health Aide (CHHA) home visit, written on the “HOME HEALTH CERTIFICATION AND PLAN OF CARE” (HHCPOC- a document that provides direction of the type of nursing care a patient needs), did not have a physician’s order. 2. For Patient 2, the Staff Nurse (SN) home visits, ordered by the physician, was not reflected on the HHCPOC. 3. For Patient 4, the SN home visits, written on the HHCPOC did not have a physician’s order. 4. For Patient 5, the SN home visits, ordered by the physician was not reflected on the HHCPOC. These failures had the potential for unmet care needs for Patients 1, 2, 4, and 5 due to missed visits, and delayed care. Findings: 1. A review of Patient 1’s clinical record, the “face sheet (contains demographic and medical information)” indicated Patient 1 had a start of care date of May 4, 2023, with a certification period (dates of when the patient receives benefits) of July 3, 2023, through August 31, 2023. Further review indicated Patient 1 had diagnoses of quadriplegia (unable to move both arms and legs), pressure ulcer (an injury that breaks down the skin and underlying tissue), and pain disorder. A review of Patient 1’s “HHCPOC,” dated May 4, 2023, through July 2, 2023, indicated Patient 1 had an order to receive CHHA home visits three to five times a week. A review of Patient 1’s “Admission Order,” dated with a certification period of May 4, 2023, through July 2, 2023, indicated there were no orders for CHHA home visits. During a concurrent interview and record review, with the Director of Patient Care Service Designee (DPCSD), on July 31, 2023, at 9:34 AM, the DPCSD reviewed Patient 1’s “HHCPOC”, and “Admission Order” for the certification period from May 4, 2023, through July 2, 2023. The DPCSD stated the documents did not match. The DPCSD further stated the documents should match and should have been filled out accurately. 2. A review of Patient 2’s clinical record, the “face sheet,” indicated Patient 2 had a start of care date of June 26, 2017, with a certification period of May 26, 2023, to July 24, 2023. Further review indicated Patient 2 had diagnoses of acute and chronic respiratory failure with hypoxia (not get enough oxygen to the body), obstructive sleep apnea (episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen), and epilepsy (a nerve disorder which can causes uncontrolled body movements and loss of level of consciousness). A review of Patient 2’s “MD (Medical Doctor) Order,” dated with a certification period of May 26, 2023, through July 24, 2023, indicated an order for SN home visit daily. A review of Patient 2’s “HHCPOC,” dated certification period of May 26, 2023, through July 24, 2023, indicated “LVN Nursing 1440 Units (one unit equals 15 minutes- 360 hours) a month and RN 8 hours per month were to be provided to Patient 2 (totaling to 368 hours per month).” (It did not indicate daily SN home visits.) During a concurrent interview and record review, on July 31, 2023, at 10:10 AM, with the DPCSD, the DPCSD reviewed Patient 2’s “HHCPOC” and “MD Order” for the certification period from May 26, 2023, through July 24, 2023, and stated the documents did not match. The DPCSD stated both documents should have matched and had the same SN home visits. 3. A review of Patient 4’s clinical record, “face sheet” indicated Patient 4 had a start of care of July 1, 2017, with a certification period of May 31, 2023, to July 29, 2023. Patient 4 had diagnoses of spastic quadriplegia (stiff muscles to both arms and legs and is unable to move), respiratory failure, and microcephaly (smaller head size). A review of Patient 4’s “HHCPOC,” dated certification period of May 31, 2023, through July 29, 2023, indicated “LVN to provide 960 Units (240 hours) of private duty nursing care monthly. RN Case Manager to provide 8 Units per month for Case Management and Supervisory visits…”. A review of Patient 4’s “MD Order,” dated with a certification period of May 31, 2023, through July 29, 2023, indicated there were no orders for SN home visits. During a record review, on July 31, 2023, at 10:55 AM, with the DPCSD, the DPCSD reviewed Patient 4’s “HHCPOC” and “MD Order” for the certification period from May 31, 2023, to July 29, 2023, and stated documents did not match. The DPCSD stated both documents should have matched and had the same SN home visits. 4. A review of Patient 5’s clinical record, “face sheet,” indicated Patient 5 had a start of care date of November 7, 2019, with a certification period of April 20, 2023, through June 18, 2023. Further review indicated Patient 5 had diagnoses of end stage renal disease (kidneys no longer filter and work) and polycystic kidney (kidneys having a lot of fluid filled sacs). A review of Patient 5’s “HHCPOC,” dated certification period of April 20, 2023, through June 18, 2023, indicated “LVN to provide 1200 units (300 hours)/ month…RN Supervisory visit 8 units (2 hours)/ month…”. A review of Patient 5’s “MD Order,” dated with a certification period of April 20, 2023, through June 18, 2023, indicated there were no orders for SN home visits. During a record review, on July 31, 2023, at 10:02 AM, with the DPCSD, the DPCSD reviewed Patient 5’s “HHCPOC” and “MD Order” for the certification period from April 20, 2023, through June 18, 2023, and stated the documents did not match. The DPCSD further stated both documents should have matched. During a concurrent interview and record review on July 31, 2023, at 11:03 AM, with the DPCSD, the agency’s undated policy and procedure, titled, “Physician Orders- Verbal Orders,” was reviewed. The P&P indicated, “… Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN or qualified therapist responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the plan of care… All verbal orders must be subsequently signed by the physician (within 30 day) …”. The DPCSD stated the P&P was not followed and should have been. During further interview and record review on July 31, 2023, at 11:07 AM, with the DPCSD, the agency’s undated P&P titled, “ENTRIES INTO THE CLINICAL RECORD,” was reviewed. The P&P indicated, “…Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The record format will be reviewed and updated as necessary…”. The DPCSD stated the P&P was not followed and it should have been to make sure the patient was receiving accurate care. During a concurrent interview and record review on July 31, 2023, at 2:40 PM, with the DPCSD, the agency’s undated P&P titled, “Plan of care- CMS# 485 and Physician Orders,” was reviewed. The “Plan of care- CMS# 485” indicated, “…5. All patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all Agency staff are working from a current plan…the plan of care is updated to reflect all current ongoing orders including any verbal orders received during the 60-day period… 22. Verbal orders are accepted only by personnel authorized to do so by applicable state laws and regulations and Agency policy. Verbal orders are put in writing, signed, timed and dated with the date of receipt by a RN…It is the RN’s or therapist’s responsibility to make any necessary revisions to the Plan of Care based on that order (s).23. Orders are verified when: There are questions or discrepancies with orders. A person taking a verbal order is not qualified to review the order for appropriateness…25. All clinical services are implemented only in accordance with a Plan of Care established by a physician’s written order…”. The DPCSD stated the policy was not followed for Patients 1, 2, 4, and 5 and stated it should have been followed because it is important for the continuity of care and to make sure the patient is getting the accurate care orders.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services were administered as ordered by the physician for two out of seven sampled patients (Patients 2 and 3) when: 1. Patient 2 was missing six Staff Nurse (SN- Licensed Vocational Nurse (LVN) or Registered Nurse (RN)) home visits for the month of June 2023. 2. Patient 3 was missing 14 Certified Home Health Aide (CHHA) home visits from June 2, 2023, through July 31, 2023. These failures caused Patients 2 and 5 to receive care that was not approved and reviewed by a physician. Findings: 1. A review of Patient 2’s clinical record, the face sheet (contains demographic and medical information) indicated Patient 2 had a start of care date of June 26, 2017, with a certification period of May 26, 2023 through July 24, 2023. Further review indicated Patient 2 had diagnoses of acute and chronic respiratory failure with hypoxia (not get enough oxygen to the body), obstructive sleep apnea (episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen), and epilepsy (a nerve disorder which can causes uncontrolled body movements and loss of level of consciousness). A review of Patient 2’s “MD (Medical Doctor) order”, dated May 22, 2023, indicated an order for Patient 2 to receive SN home visits daily for the certification period of May 26, 2023 through July 24, 2023. During a concurrent interview and record review, on July 28, 2023, at 12:35 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed the SN home visit notes for the certification period of May 26, 2023, to July 24, 2023, and acknowledged Patient 2 did not receive SN home visits on the following dates: June 9, 2023, June 10, 2023, June 15, 2023, June 19, 2023, June 27, 2023, and July 8, 2023. The DPCSD stated she did not know why the five home visits were not provided by SN but it should not have been missed. 2. A review of Patient 3’s clinical record, the face sheet indicated Patient 3 had a start of care date of April 3, 2023, with a certification period of June 2, 2023, through July 31, 2023. Further review indicated Patient 3 had diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes (high blood sugar levels), and dysphagia (difficulty swallowing). A review of Patient 3’s “MD order”, dated June 2, 2023, indicated an order for Patient 3 to receive Certified Home Health Aide (CHHA) home visits three times a week for the certification period of June 2, 2023, through July 31, 2023. During a concurrent interview and record review, on July 31, 2023, at 10:43 AM, with the DPCSD, the DPCSD reviewed and acknowledged Patient 3’s CHHA home visits from June 4, 2023 through July 28, 2023, which indicated Patient 3 had missing CHHA home visits on the following weeks: a. June 4, 2023, to June 10, 2023: CHHA home visit conducted on June 6, 2023 (Two missed visits) b. Junes 11, 2023, to June 17, 2023: CHHA home visit conducted on June 11, 2023. (Two missed visits) c. June 18, 2023, to June 24, 2023: CHHA home visit conducted on June 19, 2023. (Two missed visits) d. June 25,2023, to July 1, 2023: No CHHA home visits (Three missed visits) e. July 2, 2023, to July 8, 2023: CHHA home visit conducted on June 8, 2023. (Two visits missed) f. July 9, 2023, to July 15, 2023: CHHA home visit conducted on July 12, 2023, and July 15, 2023. (One missed visit) g. July 16, 2023, to July 22, 2023: CHHA home visit conducted on July 19, 2023, and July 22, 2023. (One missed visit) h. July 23, 2023, to July 29, 2023: CHHA home visit conducted on July 24, 2023, and July 25, 2023. (One missed visit) During an interview on July 31, 2023, at 10:46 AM, with the DPCSD, the DPCSD stated Patient 3 should have been provided CHHA home visits three times a week and was not sure why Patient 3 had 14 missed home visits. During a concurrent interview and record review on July 31, 2023, at 11:03 AM, with the DPCSD, the DPCSD reviewed the agency’s undated policy and procedure (P&P) titled, “Physician Orders- Verbal Order,” which indicated, “Drugs and treatments are administered by the Agency staff only as ordered by the physician…”. The DPCSD stated the policy was not followed and should have been followed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure accurate medical record was maintained for one of seven sampled patients (Patient 2), when the agency was not able to provide the physician's referral order (order requesting the agency to assess the patient in order to make a determination if the patient is to be admitted to the agency) and start of care orders (SOC orders- when the patient is starting to receive care from the new agency). This failure had the potential to cause staff to provide delayed care for Patient 2, placing Patient 2's health at risk. Findings: A review of Patient 2’s clinical record, the “face sheet,” indicated Patient 2 had a start of care date of June 26, 2017, with a certification period of May 26, 2023 through July 24, 2023. Further review indicated Patient 2 had diagnoses of acute and chronic respiratory failure with hypoxia (not get enough oxygen to the body), obstructive sleep apnea (episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen), and epilepsy (a nerve disorder which can causes uncontrolled body movements and loss of level of consciousness). During a concurrent interview and record review on July 31, 2023, at 11:00 AM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 2’s clinical record and was unable to find Patient 2’s referral and SOC orders. The DPCSD further stated, “I am not able to find the start of care order and the referral order in the chart and I know the other staff looked everywhere for the records and was not able to find it either, so we don’t have it.” The DPCSD acknowledged they should have had it in the chart. During a concurrent interview and record review on July 31, 2023, at 11:05 AM, with the DPCSD, the DPCSD reviewed the agency’s undated policy and procedure (P&P) titled, “Retention of Records,” which indicated, “To comply with applicable law and regulation regarding the retention of clinical records. The clinical record will be retained for seven years from the month in which the agency’s cost report to which the record (s) applies is filed with the intermediary or seven years after the end of the fiscal year to which the record (s) applies, unless state law stipulates longer…1. All active (open) records will be filed alphabetically and stored in a secure area with access by home care personnel only…”. The DPCSD stated the policy was not followed because they were not able locate and provide the records. During a subsequent interview and record review on July 31, 2023, at 11:07 AM, with the DPCSD, the DPCSD reviewed the agency’s undated P&P titled, “Medical Record Content,” which indicated, “The Agency will provide an accurate and current medical record for every patient seen by the agency…1. The Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal/state laws and regulations…4. Each medical record will contain the following…Any referrals to internal or external providers/ agencies…”. The DPCSD stated the policy was not followed.