Every finding on record at St Luke's Home Health Services, Inc

The following reflects the findings of the California Department of Public Health during the Complaint Investigation for Complaint Number: 3044726. The survey team entered the home health agency on 6/17/26 at 0930 hours. The home health agency identified the census as 46. The survey sample size was 4. * FOR COMPLAINT NUMBER: 3044726: NO DEFICIENCIES WERE IDENTIFIED. HOWEVER, DURING THE COMPLAINT INVESTIGATION, ADDITIONAL DEFICIENCIES WERE IDENTIFIED AND CITED AT G0614, G0710, and G1024. GLOSSARY AND DEFINITIONS: CEO: Chief Executive Officer CHHA: Certified Home Health Aide DPCS: Director of Patient Care Services HHA: Home Health Agency LVN: Licensed Vocational Nurse MD: Medical Doctor PCG: Primary Caregiver PEG tube: Percutaneous Endoscopic Gastrostomy tube (a medical device used to deliver nutrition, fluids, and sometimes medications directly into a patient’s stomach, bypassing the mouth and esophagus) POC: Plan of Care RN: Registered Nurse SN: Skilled Nursing/Nurse SOC: Start of Care W: Week

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written visit schedule provided to one of four sampled patients (Patient 4) was consistent with the patient's most current plan of care. This failure had the potential of creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 4’s clinical record was initiated on 6/17/26. The clinical record showed the SOC was 12/22/25. The patient was certified for home health services during the certification periods from 12/22/2025 to 2/19/2025, 2/20/2026 to 4/20/2026, and 4/21/2026 to 6/19/2026. The POC, for the certification periods from 4/21/2026 to 6/19/2026, showed SN visits 1W9 (one visit a week for nine weeks). A joint home visit with LVN 1 was conducted on 6/18/26 at 0900 hours, to Patient 4’s home. Patient 4’s Admission Packet was reviewed. The Projected Home Visit Schedule Frequency Calendar was blank for the SN visit frequency and episode dates. LVN 1 was asked if it should have been filled up and completed, LVN 1 verified it was missed and should have been completed. On 6/18/26 at 1500 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS. The CEO and DPCS were informed and verified the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the SN provided education to the patient/PCG as per the POC for two of four sampled patients (Patients 1 and 2). This failure created the risk of not providing the necessary care and services to these patients. Findings: 1. Review of Patient 1's closed clinical record was initiated on 6/17/26. The closed clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification periods from 8/18/2025 to 10/16/2025, 10/17/2025 to 12/15/2025, 12/16/2025 to 2/13/2026, 2/14/2026 to 04/14/2026, and 04/15/2026 to 06/13/2026. The patient was discharged on 6/12/26. Review of the POC for the certification period from 4/15/26 to 6/13/26, showed skilled nurse to teach/instruct the patient/patient caregiver on PEG care. Review of the SN Nursing Progress Notes dated 4/15. 4/16, 4/17, 4/18, 4/19, 4/20, 4/22, 4/27, 4/29, 5/5, 5/7, 5/11, 5/14, 5/18, 5/20, 5/21, 5/25, 5/27, 6/1, 6/3, 6/8, and 6/10/26 showed no documented evidence the SN followed the physician's order to teach/instruct patient/caregiver on PEG tube care. On 6/18/26 at 1515 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings. 2. Review of Patient 2's closed clinical record was initiated on 6/17/26. The clinical record showed the SOC was 1/15/26. The patient was certified for home health services during the certification period from 1/15/26 to 3/15/26. The patient was discharged on 2/25/26. Review of the POC, for certification period from 1/15/26 to 3/15/26, showed the following: -SN to teach/instruct/train the patient/caregiver regarding dietary regimen. -Goals/rehabilitation, potential/discharge plans/referral plan/other notes showed patient/caregiver would verbalize understanding on low salt/fat/cholesterol diet as evidenced by compliance with diet plan in four to six weeks. Review of the SN Nursing Progress Notes dated 1/19 , 1/23, 1/26, 1/30, 2/6, 2/14, and 2/18/26, showed no documented evidence the SN followed the physician's order to teach/instruct patient/caregiver on the dietary regimen. On 6/18/26 at 1044 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical record was completed for one of four sampled patients (Patient 1). This failure created the risk of not having the accurate information in the patient's clinical record. Review of Patient 1's closed clinical record was initiated on 6/17/26. The closed clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification periods from 8/18/2025 to 10/16/2025, 10/17/2025 to 12/15/2025, 12/16/2025 to 02/13/2026, 02/14/2026 to 04/14/2026, and 04/15/2026 to 06/13/2026. The patient was discharged on 6/12/26. Review of the Communication notes showed the HHA felt unsafe: -On 9/8/25, the family member visited the agency with the transportation denial letter, previous hospital papers, and pad papers with care information of the patient. The communication note included the family member verbalized that he got banned from six different hospitals due to accusation of assault to the MD and threatening to come back and packing with a gun but nothing were true as he mentioned. -On 2/11/26, received a report from RN 1 that during her visit, she felt unsafe because the family member was verbally making her feel uncomfortable with comments he was making in regards to be being banned from all Orange County hospitals. RN verbalized her hesitance to continue visiting the patient. Agency verbalized understanding and stated they will document all reports received. MD was aware and notified -On 4/17/26, the family member came by the office today to stop by and pay "us" a visit. The family member then mentioned the following, " yes I might make you guys suffer a bit more and make you work." The agency requested further clarification in regards to his statement but the family member laughed and walked away. The MD was notified. - On 5/26/26, received report from CHHA 1 that during the visit, CHHA 1 witnessed an argument the family member and the partner had. CHHA 1 stated the partner said, "he's really on a role today and I might call the cops on him." CHHA 1 wanted to inform agency of situation she experienced. The MD was notified. On 6/17/26 at 1158 hours, an interview was conducted with the CEO. The CEO was asked about Patient 1's discharge. The CEO stated on 6/1/26, the HHA received report from LVN 1 that LVN 1 would be resigning in two weeks; and the family member and MD was informed. The CEO further stated the agency's other licensed staff nurses were requested to render their skilled nursing services to Patient 1; however the agency's other licensed nurses refused because they were not comfortable with the family member. The CEO added RN 1 who used to go to Patient 1 even asked for LVN 1's presence because RN 1 felt unsafe. The CEO mentioned RN 1 already resigned because of the family member. Additionally, the CEO stated the agency had been assisting the patient for HHA referrals, and the HHA was just waiting for the decision on which HHA the family member preferred. However, review of the closed clinical record showed no documented evidence the reasons for discharge included the unsafe environment for staff. On 6/18/26 at 1610 hours, an interview was conducted with the CEO and DPCS. The CEO and DPCS were informed and verified the findings.

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION Surveys. The survey team entered the home health agency on 5/13/26 at 0900 hours. The home health agency identified the census as 44. The survey sample size was 8. GLOSSARY AND DEFINITIONS: CEO: Chief Executive Officer

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included strategies for addressing emergency events identified by the risk assessment. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency's 2025 emergency preparedness program documents was conducted on 5/19/26, and showed the plan did not address the strategies for addressing bomb threat emergency event as identified by the risk assessment. On 5/20/26 at 0839 hours, an interview and concurrent record review was conducted with the CEO. The CEO verified the above finding.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the communication plan that address how the facility interacts and coordinates with emergency management agencies and systems to protect patient health and safety in the event of a disaster. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Review of the agency's 2025 emergency preparedness program documents was conducted on 5/19/26, and showed the communication plan did not address how the facility interacts and coordinates with emergency management agencies and systems to protect patient health and safety in the event of a disaster. On 5/20/26 at 0838 hours, an interview and concurrent document review was conducted with the CEO. The CEO was informed and acknowledged the above finding.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS Surveys. The survey team entered the home health agency on 5/13/26 at 0900 hours. The home health agency identified the census as 44. The survey sample size was 8. GLOSSARY AND DEFINITIONS: AV fistula: arteriovenous fistula (a connection created between an artery and a vein) Bladder irrigation: a medical procedure that flushes the bladder with sterile fluid to remove blood clots, debris, or mucus and maintain urine flow. bruit: a sound heard over an artery or vascular channel, reflecting turbulence of flow cc: cubic centimeter CEO: Chief Executive Officer CM: Case Manager Dementia: group of symptoms affecting memory, thinking, and social abilities Diabetes mellitus: a disease of inadequate control of blood levels of glucose DPCS: Director of Patient Care Services EENT: Eye, Ear, Nose, and Throat Endocrine: the body's network of glands and organs that produce and release and hormones. ER: Emergency Room Foley catheter: also called an indwelling urinary catheter, is a medical device used to drain urine from the bladder into an external collection bag when normal urination is difficult or impossible. French: unit of measurement used to measure the outer diameter of cylindrical medical instruments, most commonly catheters GACH: General Acute Care Hospital HHA: Home Health Agency LVN: Licensed Vocational Nurse mg: milligram(s) MSW: Medical Social Worker OASIS: Outcome and Assessment Information Set Parkinson's Disease: a neurodegenerative disease affecting both motor and non-motor systems. PEG:percutaneous endoscopic gastrostomy tube (a medical device surgically inserted through the abdomen directly into the stomach) PCG: Primary Caregiver pneumonia: infection of the lungs P&P: Policy and Procedure PO: By mouth POC: Plan of Care PRN: As Needed PT: Physical Therapy/Therapist Q: Every QA: Quality Assurance QAPI: Quality Assurance and Performance Improvement RN: Registered Nurse Sacrum: a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis SN: Skilled Nursing/Nurse SOB: shortness of breath SOC: Start of Care Stage 4 pressure injury: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling thrill: a vibratory sensation felt on the skin overlying an area of turbulence UTI: Urinary tract Infection W: Week

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OASIS data were transmitted within 30 days of completing the OASIS data sets. This failure had the potential for not reporting and coordinating the patient care assessment timely for the patients receiving care and services at the agency. Findings: Review of the Agency Error Summary Report for 5/5/25 to 5/5/26, was initiated on 5/15/26. The Agency Error Summary Report for 5/5/25 to 5/5/26, showed five OASIS data sets were submitted more than 30 days from the assessment completion date. On 5/15/26 at 0805 hours, an interview and concurrent document review was conducted with the CEO. The CEO confirmed the five OASIS data sets were submitted late.

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 the medication profiles were reviewed and updated for two of eight sampled patients (Patients 2 and 3). This failure had the potential for the patients not to receive the appropriate care and necessary services and negatively affect the patients' well-being. Findings: Review of the agency’s P&P titled Medication Profile revised 1/2004 showed patients receiving medications will have a current accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. 1. Review of Patient 2’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 10/23/24. The patient was certified for home health services during the certification periods from 10/23/24 to 12/21/24, 12/22/24 to 2/29/25, 2/20/25 to 4/20/25, 4/21/25 to 6/19/25, 6/20/25 to 8/18/25, 8/19/25 to 10/17/25, 10/18/25 to 12/16/25, 12/17/25 to 2/14/26, 2/15/26 to 4/15/26, and 4/16/26 to 6/14/26. The Patient Medication Profile for the certification period from 4/16/26 to 6/14/26, showed the patient’s medication included ibuprofen (pain medication) 600 mg one tablet by mouth at bedtime. A joint home visit with LVN 1 was conducted on 5/14/26 at 1130 hours, to Patient 2’s home. The medication bottle at the patient’s home showed ibuprofen 600 mg one tablet by mouth three times a day with food/milk as needed. However, there was no documented evidence the medication profile was updated to show the frequency of the above medication. LVN 1 confirmed the above finding. On 5/20/26 at 0843 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and verified the findings. 2. Review of Patient 3’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification period from 3/27/26 to 5/25/26. The Patient Medication Profile for the certification period from 3/27/26 to 5/25/26, showed the patient’s medication included pramipexole (medication used to treat Parkinson’s disease) 0.5 mg one tablet by mouth every evening. A joint home visit with PT 1 was conducted on 5/14/26 at 1500 hours, to Patient 3’s home. The PCG stated Patient 3 was weaned off from pramipexole and it was discontinued about two weeks ago. Furthermore, the PCG stated Patient 3 started on gabapentin (medication used to treat nerve pain) a couple of months ago. Gabapentin was administered until the patient was weaned off from pramipexole. However, there was no documented evidence the medication profile was updated to reflect the patient’s current medications to include gabapentin and remove pramipexole. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and verified the findings.

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 to follow the physician's orders for two of eight sampled patients (Patients 5 and 8). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 5's closed clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/1/23. The patient was certified for home health services during the certification period from 8/1/23 to 9/29/23, 9/30/23 to 11/28/23, 11/29/23 to 1/27/24, 1/28/24 to 3/27/24, 3/28/24 to 5/26/24, 5/27/4 to 7/25/24, 7/26/24 to 9/23/24, 9/24/24 to 11/22/24, 11/23/24 to 1/21/25, 1/22/25 to 3/22/25, 3/23/25 to 5/21/25, 5/22/25 to 7/20/25, 7/21/25 to 9/18/25, 9/19/25 to 11/17/25, and 11/18/25 to 1/16/26. The patient was discharged on 1/8/26. Review of Physician's Order/Telephone Order dated 11/24/25, showed to send MSW for evaluation and as needed 1-2 follow up visits. Review of the agency's visit calendar for certification period from 11/18/25 to 1/16/26 showed no documentation of MSW visits. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked to show MSW visits documentation as ordered by the physician. The Administrator/DPCS verified she could not find any documentation of MSW visits and further stated the physician's order should have been followed. 2. Review of Patient 8's clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification period from 8/18/25 to 10/16/25, 10/17/25 to 12/15/25, 12/16/25 to 2/13/26, 2/14/26 to 4/14/26 and 4/15/26 to 6/13/26. Review of Patient 8's POC dated 4/15/26 for certification period from 4/15/26 to 6/13/26, showed a physician's order for SN to teach/instruct patient/caregiver on the following: -management and treatment of disease process and wound care -signs and symptoms of infection, infection control -PEG -Foley catheter care, signs and symptoms of UTI -bleeding -medications to include action, dose, frequency, route of administration, adverse side effects. In addition, the orders for discipline and treatment showed SN to perform bladder irrigation through Foley catheter every visit. The PCG would perform bladder irrigation through Foley catheter on non SN visit days: Bladder Irrigation- 1:20 ratio of white vinegar to water and instill 60cc then aspirate 30cc through Foley catheter daily and as needed to prevent clogging. Review of the SN visits dated 4/16, 4/17, 4/18, 4/19, 4/20, 4/22, 4/27, 4/29, 5/5, and 5/7/26, showed the completed assessments from head to toe. However there was no documentation of the bladder irrigation through Foley catheter every SN visits conducted. On 5/20/26 at 0831 hours, an interview and concurrent record review was conducted with the Administrator and DPCS. The Administrator/DPCS was informed and verified the physician's orders should have been followed.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient and PCG were provided education regarding the care identified in the POC for five of eight sampled patients (Patients 1, 5, 6, 7, and 8). This failure has the potential for not addressing the care needs for these patients. Findings: 1. Review of Patient 7’s clinical record was initiated on 5/19/26. The clinical record showed the SOC was 3/13/26. The patient was certified for home health services during the certification periods from 3/13/26 to 5/11/26 and 5/12/26 to 7/10/26. Review of the communication note dated 3/19/26, showed Patient 7 went to GACH ER due to complaints of left arm swelling and pain. Review of the physician’s telephone order dated 3/31/26, showed Patient 7 was discharged from GACH due to left arm swelling and pain. Documentation showed the patient had complication with the fistula on the left upper extremity that required coiling. A resumption of care (after inpatient stay) was ordered. In addition, the order included teaching and training and follow up for the patency of the left forearm "AV fistula (shunt)." Review of the resumption of care assessment dated 3/31/26, showed RN 2 noted left forearm AV fistula to be patent and positive for thrill/bruit. However, there was no documented evidence the teaching and training were provided to keep the left forearm AV fistula free from any complications. On 5/20/26 at 0906 hours, an interview and concurrent clinical record review were conducted with the CEO and RNCM/QA. The RNCM/QA verified the findings. 2. Review of Patient 1's clinical record was initiated on 5/13/26. The clinical record showed the SOC was 2/5/26. The patient was certified for home health services during the certification period from 4/6/26 to 6/4/26. Review of Patient 1's POC for certification period from 4/6/26 to 6/4/26, showed the medications included aspirin (blood thinner) 81 mg oral tablet daily. The POC showed SN to teach/instruct patient/patient caregiver on the following: -on the management and treatment of diabetes, stroke, hypertension, and hyperlipidemia, -measures to recognize cardiac dysfunction and relieve complications, recognizing warning signs of stroke -bleeding/universal/covid-19 precautions, signs and symptoms of disease exacerbation/complications, pain management, -medications to include action, dose, frequency, route of administration, adverse side effects, Review of the SN notes dated 4/13, 4/20, 4/26, 5/7, and 5/12/26, showed Patient 1 was assessed from head to toe. *However there was no documented evidence the teaching/instructions were provided to the patient/caregiver on signs and symptoms of bleeding related to aspirin use. On 5/20/26 at 0815 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and verified the finding. 3. Review of Patient 5's closed clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/1/23. The patient was certified for home health services during the certification period from 8/1/23 to 9/29/23, 9/30/23 to 11/28/23, 11/29/23 to 1/27/24, 1/28/24 to 3/27/24, 3/28/24 to 5/26/24, 5/27/4 to 7/25/24, 7/26/24 to 9/23/24, 9/24/24 to 11/22/24, 11/23/24 to 1/21/25, 1/22/25 to 3/22/25, 3/23/25 to 5/21/25, 5/22/25 to 7/20/25, 7/21/25 to 9/18/25, 9/19/25 to 11/17/25, and 11/18/25 to 1/16/26. The patient was discharged on 1/8/26. Review of the Physician's Order/Telephone Order dated 12/22/26, showed a change of dosage for quetiapine (antipsychotic) from 25 mg to 50 mg, one tablet by mouth daily in the afternoon. The order showed SN to teach/instruct/train the patient/PCG on new medication (action, dose, frequency and side effects), administration, disease process, sign and symptoms of infection, complications/management, etc. Review of the SN notes dated 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/30, 12/31/25, 1/1, 1/2, and 1/3/26, showed the completed assessments on mental status, cardiovascular, respiratory, EENT, motor/musculoskeletal, pain, gastrointestinal, genitourinary, endocrine, integumentary, wound, and venous assessment. *However, there was no documented evidence of the SN following the physician's order to teach/instruct/train patient/caregiver on the new medication order. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed on the new medication dosage order of quetiapine and verified that education should have been provided to the patient/caregiver as ordered by the physician. 4. Review of Patient 6's clinical record was initiated on 5/13/26. The clinical record showed the SOC was 3/23/26. The patient was certified for home health services during the certification period from 3/23/26 - 5/21/26. Review of the Medication Profile showed a physician's order that included aspirin 81 mg one tablet oral daily for prophylaxis. Review of the POC dated 3/23/26, showed SN to teach/instruct/train the patient/PCG on the following: -disease process/management/complications, medication regimen (purpose, side effects, dosage and frequency) - signs/symptoms of bleeding. Review of the SN notes dated 3/27, 4/1/, 4/3, 4/8, 4/15, 4/22, 4/29, 5/6, and 5/13/26, showed the completed assessments on mental status, cardiovascular, respiratory, EENT, motor/musculoskeletal, pain, gastrointestinal, genitourinary, endocrine, integumentary, wound, and venous assessment. *However, there was no documented evidence of the SN following the physician's order to teach/instruct/train the patient /caregiver on medication regimen (purpose, side effects, dosage and frequency), and signs and symptoms of bleeding. On 5/20/26 at 0825 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS acknowledged there was no documentation from the dates mentioned and verified the physician's order to provide the patient/caregiver with education on aspirin medication and signs and symptoms of bleeding should have been followed. 5. Review of Patient 8's clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification period from 8/18/25 to 10/16/25, 10/17/25 to 12/15/25, 12/16/25 to 2/13/26, 2/14/26 to 4/14/26, and 4/15/26 to 6/13/26. Review of Patient 8's POC dated 4/15/26 for certification period from 4/15/26 to 6/13/26, showed a physician's order for skilled nurse to teach/instruct the patient/caregiver on the following: -management and treatment of disease process and wound care -signs and symptoms of infection, infection control -PEG -foley catheter care, signs and symptoms of UTI -bleeding -medications to include action, dose, frequency, route of administration, adverse side effects. In addition, the orders for discipline and treatment showed SN to perform bladder irrigation through Foley catheter every visit. The PCG would perform bladder irrigation through Foley catheter on non SN visit days: Bladder Irrigation- 1:20 ratio of white vinegar to water and instill 60 cc then aspirate 30 cc through Foley catheter daily and as needed to prevent clogging. Review of the Medication Profile for certification period from 4/15/26 to 6/13/26, showed a physician's order dated 8/18/25, for aspirin 81 mg one tablet via G-tube daily. a. Review of the SN notes dated 4/16, 4/17, 4/18, 4/19, and 4/20/26, showed the completed assessments on mental status, cardiovascular, respiratory, EENT, motor/musculoskeletal, pain, gastrointestinal, genitourinary, endocrine, integumentary, wound, and venous assessment. *However, there was no documented evidence the SN followed the physician's order to provide education to the patient/caregiver on signs and symptoms of bleeding, infection, UTI, PEG care, and Foley catheter care. b. Review of the SN visits dated 4/16, 4/17, 4/18, 4/19, 4/20, 4/22, 4/27, 4/29, 5/5, and 5/7/26, showed the completed assessments from head to toe. *However there was no documentation the education was provided to the caregiver to perform bladder irrigation through Foley catheter on non-SN visit days. On 5/20/26 at 0831 hours, an interview and concurrent record review was conducted with the Administrator and DPCS. The Administrator/DPCS was informed and verified the physician's orders should have been followed.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s skilled professionals prepared accurate clinical notes for two of eight sampled patients (Patient 2 and 7). This failure had the potential risk of creating a substandard healthcare outcome for these patients. Findings: 1. Review of Patient 2’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 10/23/24. The patient was certified for home health services during the certification period from 10/23/24 to 12/21/24, 12/22/24 to 2/29/25, 2/20/25 to 4/20/25, 4/21/25 to 6/19/25, 6/20/25 to 8/18/25, 8/19/25 to 10/17/25, 10/18/25 to 12/16/25, 12/17/25 to 2/14/26, 2/15/26 to 4/15/26, and 4/16/26 to 6/14/26. a. Review of the Recertification Assessment dated 4/15/26, showed Patient 2 had anemia and was taking ferrous sulfate (medication for iron deficiency) 325 mg one tablet by mouth once a day. However, review of the Patient Medication Profile for the certification period from 4/16/26 to 6/14/26, did not include the mentioned medication which was inconsistent with the Recertification Assessment. b. Review of the Nursing Progress Note dated 4/30 and 5/7/26, showed in the narrative section, LVN 1 cleansed Stage 4 sacrococcyx pressure injury with wound cleanser, patted dry with gauze, applied Skin-Prep (protective wipes) to the periwound, applied Vitastem (antibiotic spray), medical grade honey and calcium alginate with silver (antimicrobial wound dressing) to the wound bed, and covered with a foam dressing. However, review of the Wound Care Worksheet dated 4/30 and 5/7/26, showed the treatment order to cleanse Stage 4 sacrococcyx pressure injury with wound cleanser, pat dry with gauze, apply Skin-Prep to the periwound, apply Vitastem and collagen powder (topical wound care) to the wound bed, and cover with a bordered foam dressing which was inconsistent with the SN Notes. On 5/20/26 at 0843 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO confirmed the findings. 2. Review of Patient 7’s clinical record was initiated on 5/19/26. The clinical record showed the SOC was 3/13/26. The patient was certified for home health services during the certification periods from 3/13/26 to 5/11/26 and 5/12/26 to 7/10/26. a. Review of the Patient Referral and Order Form dated 2/24/26, showed an order for a Social Worker for transportation and assistance to and from dialysis. Review of the POC, for the certification period from 3/13/26 to 5/11/26, showed MSW 1-2 visits for 60 days for evaluation, psychosocial assessment, community resources/services referral, counseling, and long-term planning. However, review of the Medical Social Services Discharge Summary dated 4/1/26, the MSW did not specify information on the transportation and assistance to and from dialysis in the community referrals. b. Review of the Nursing Progress Note dated 4/7/26, showed in the narrative section, LVN 2 noted Patient 7 took losartan hydrochlorothiazide (antihypertensive) 50-12.5 mg one tablet by mouth and carvedilol (antihypertensive) 12.5 mg one tablet by mouth. However, review of the Home Health Certification and Plan of Care for the certification period from 3/13/26 to 5/11/26, did not include the abovementioned medications. On 5/20/26 at 0906 hours, an interview and concurrent clinical record review was conducted with the CEO and RNCM/QA. The CEO and RNCM/QA confirmed the findings.

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 interview and record review, the agency's Administrator failed to be responsible for the agency's day-to-day operations which included: -The written agreements failed to address the role of the agency and the contracted individual in discharge planning for Contractors 3 and 4. -The implementation of the agency's P&P related to the maintenance of the patient's clinical records specifically the Patient Arbitration Agreement for four of eight sampled patients (Patients 2, 3, 4, and 7). These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the agency’s P&P titled Entries Into the Clinical Record revised 1/2004, showed documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. A clinical record will be initiated and maintained for each patient receiving care or services and include among other the client consent authorization, and elections forms, as applicable. 1.Review of Patient 2’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 10/23/24. The patient was certified for home health services during the certification period from 10/23/24 to 12/21/24, 12/22/24 to 2/29/25, 2/20/25 to 4/20/25, 4/21/25 to 6/19/25, 6/20/25 to 8/18/25, 8/19/25 to 10/17/25, 10/18/25 to 12/16/25, 12/17/25 to 2/14/26, 2/15/26 to 4/15/26 and 4/16/26 to 6/14/26. Review of the Consent/Admission/Recertification Service Agreement dated 10/23/24, showed the Patient Arbitration Agreement was left blank. On 5/20/26 at 0843 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and verified the findings. 2.Review of Patient 3’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification period from 3/27/26 to 5/25/26. Review of the Consent/Admission/Recertification Service Agreement dated 3/27/26, showed the Patient Arbitration Agreement was left blank. Furthermore, the consent was signed by a patient or authorized representative, however, the reason why patient did not sign was not indicated. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and confirmed the findings. 3.Review of Patient 4’s closed clinical record was initiated on 5/15/26. The clinical record showed the SOC was 10/30/25. The patient was certified for home health services during the certification period from 10/30/25 to 12/28/25, 12/29/25 to 2/6/26 and 2/27/26 to 4/27/26. The patient was discharged on 4/25/26. Review of the Consent/Admission/Recertification Service Agreement dated 10/30/25, showed the Patient Arbitration Agreement and Medicare Secondary Payer Screening Form were left blank. On 5/20/26 at 0904 hours, an interview and concurrent clinical record review was conducted with the CEO and RNCM/QA. The RNCM/QA acknowledged and confirmed the findings. 4.Review of Patient 7’s clinical record was initiated on 5/19/26. The clinical record showed the SOC was 3/13/26. The patient was certified for home health services during the certification periods from 3/13/26 to 5/11/26 and 5/12/26 to 7/10/26. Review of the Consent/Admission/Recertification Service Agreement dated 3/13/26, showed the Patient Arbitration Agreement was left blank. On 5/20/26 at 0906 hours, an interview and concurrent clinical record review was conducted with the CEO and RNCM/QA. The RNCM/QA acknowledged and confirmed the findings. Review of the agency's P&P title Administrator (undated) showed the administrator ensures quality and safe delivery of home health care services; coordinates services that reflect the Agency's philosophy and standards of care; plans, develops, implements and evaluates Agency services; programs and activities. Review of agency's Written Agreements for Contracted Services revised 1/2004 showed the written agreement will address discharge planning. Review of the agency's job description for Physical Therapist copyright dated 1995 showed physical therapists participate in discharge planning for patient. Review of the agency's job description for Occupational Therapist copyright dated 1995 showed occupational therapists participate in discharge planning for patient. Review of the agency's job description for Speech Language Pathologist copyright dated 1995 showed occupational therapists participate in discharge planning for patient. Review of the Contractor Agreements was initiated on 5/19/26. The contractor agreements 3 and 4 failed to include discharge planning. On 5/19/26 at 1032 hours, an interview and concurrent record review was conducted with the CEO. The CEO verified the above findings and stated agency would reach out to contractor for revision of agreement.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical records were electronically signed and dated for one out eight sampled patients (Patient 1). This failure had a potential risk on inaccuracy of the patient's clinical records. Findings: Review of the agency's P&P titled Entries into the Clinical Record revised 1/2004 showed the clinical note will include the date the service was provided and signature of clinician and his/her credentials. Review of Patient 1's clinical record was initiated on 5/13/26. The clinical record showed the SOC was 2/5/26. The patient was certified for home health services during the certification period from 4/6/26 to 6/4/26. Review of Patient 1's Recertification Assessment/ OASIS dated 4/5/26, showed RN 1 conducted complete the patient assessment documentation. However, there was no documentation showing it was electronically signed and dated. On 5/20/26 at 0818 hours, an interview and concurrent record reveiw was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN and 39539, HFEN. The survey team entered the HHA on 5/2/23 at 0900 hours. The survey team reviewed six active and two closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: CEO: Chief Executive Officer P&P: Policy and Procedure

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan included the process for cooperation and collaboration with the local, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This created the potential risk of not providing the necessary care and services to the patients during an emergency event. Findings: Review of the agency's emergency preparedness program documents was conducted on 5/4/23. The documents showed the plan did not include a process for cooperation and collaboration with the local, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. On 5/9/23 at 0952 hours, an interview and concurrent facility document review was conducted with the CEO. She was informed and acknowledged the above findings.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the agency's emergency preparedness P&P addressed the procedures to inform the State emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This failure created the increased risk of not evacuating the patients timely. Findings: Review of the agency's emergency preparedness program documents was conducted on 5/4/23. The emergency preparedness P&P failed to include the procedures to inform the State emergency preparedness officials about the patients in need of the evacuation from their residences due to an emergency situation. On 5/9/23 at 0952 hours, an interview and concurrent facility document review was conducted with the CEO. She was informed and acknowledged the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to develop the communication plan to include the name and contact information for the entities providing the services under arrangement and the patients’ physicians, creating the risk of not able to contact or request for assistance during emergency events. Findings: Review of the agency's emergency preparedness program documents was conducted on 5/4/23. There was no documented evidence the communication plan included the name and contact information for the entities providing the services under arrangement and the patients’ physicians. On 5/9/23 at 0952 hours, an interview and concurrent facility document review was conducted with the CEO. She was informed and acknowledged the above findings.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS surveys. Representing the California Department of Public Health: Surveyors 31929, HFEN and 39539, HFEN. The survey team entered the HHA on 5/2/23 at 0900 hours. The survey team reviewed six active and two closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: BID: twice a day bronchitis: inflammation of the lining of your bronchial tubes, which carry air to and from your lungs BS: Blood sugar CDC: Centers for Disease Control and Prevention Cellulitis: deep infection of the skin caused by bacteria CEO: Chief Executive Officer CHHA: Certified Home Health Aide cholecystitis: inflammation of the gallbladder conjunctivitis: inflammation of the transparent membrane that lines the eyelid and eyeball COVID 19: an infectious disease caused by the SARS-CoV-2 virus DPCS: Director of Patient Care Services HHA: Home Health Agency LVN: Licensed Vocational Nurse Mantoux tuberculin skin test: one method of determining whether a person is infected with Mycobacterium tuberculosis mcg: microgram(s) mg: milligram(s) ml: milliliter(s) OT: Occupational Therapy/Therapist PCG: Patient Care Giver OASIS: Outcome and Assessment Information Set Oxygen saturation level: a measure of how much hemoglobin is currently bound to oxygen compared to how much hemoglobin remains unbound. P&P: policy and procedure pneumonia: infection that affects one or both lungs. PO: by mouth POC: Plan of Care PPD: Purified Protein Derivative (a TB skin test measures the immune system's response to a purified protein derivative (PPD) solution injected under the skin) PRN: As needed PT: Physical Therapy/Therapist Pulse oximeter: an electronic device that measures the saturation of oxygen carried in your red blood cells. Q: Every QA: Quality Assurance QAPI: Quality Assurance and Performance Improvement QD: Every day QID: four times a day RN: Registered Nurse Sacrum: a triangular bone at the inferior portion of the spine that supports the weight of the spine superior to it SC: subcutaneous SN: Skilled Nurse SOC: Start of Care S/P: status post Stage 2 Pressure Injury/Ulcer: Partial-thickness loss of skin with exposed dermis. TB: tuberculosis (an infectious disease that most often affects the lungs and is caused by a type of bacteria) TID: three times a day URI: Upper Respiratory Infection UTI: Urinary Tract Infection W: week

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was completed accurately in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the start of care for one of eight sampled patients (Patient 4), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 4's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/10/23. The patient was certified for home health services during the certification periods from 1/10/23 to 3/10/23 and 3/11/23 to 5/9/23. The SOC assessment dated 1/12/23, showed a section of the assessment showing whether there should be a brief interview for the patient’s mental status be conducted, and the answer was no, and the patient was rarely/never understood. However, another section of the assessment, under the patient's cognitive functioning, showed the patient was alert/oriented, able to focus and shift attention, comprehends, and recalls task directions independently. The above assessment was not consistent. On 5/9/23 at 1010 hours, an interview and clinical record review was conducted with LVN 1. He was informed and acknowledged the findings.

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 the medication profiles were updated to reflect the patients' current medications; included specific indications and parameters for their use; and identified actual or potential drug interactions for three of eight sampled patients (Patients 3, 4, and 7). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. 3. Review of Patient 4's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/10/23. The patient was certified for home health services during the certification periods from 1/10/23 to 3/10/23 and 3/11/23 to 5/9/23. The Medication Profile for the certification period from 3/11/23 to 5/9/23, showed the medications included Lantus (antidiabetic) 100 units/ml injectable solution, inject 39 units SC Q morning, Jardiance (antidiabetic) 25 mg one tablet PO QD in the morning, and Novolog aspart (antidiabetic) 100 units/ml, inject 14 units SC Q 12 hours According to Lexi-Comp's pharmacology website, hypoglycemia-associated agents: May enhance the hypoglycemic effect of other hypoglycemia-associated Agents. Further review of the Medication Profile showed the medications had been reviewed for possible adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. * However, there was no documented evidence the potential drug interactions were identified for these antidiabetic agents. On 5/9/23 at 1010 hours, an interview and clinical record review was conducted with LVN 1. He was informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/17/23. The patient was certified for home health services during the certification period from 1/17/23 to 3/17/23. On 5/3/23 at 1210 hours, a joint home visit was conducted with LVN 1 to Patient 3’s home. Review of the patient’s medications with LVN 1 showed the patient was taking metformin (antihyperglycemic) 500 mg PO BID instead of TID, Naprosyn (nonsteroidal anti-inflammatory medication) 375 mg PO BID instead of QD PRN for pain, and amlodipine (antihypertensive) 5 mg PO BID instead of 50 mg PO QD as written in the medication profile. On 5/3/23 at 1245 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 verified the medication profile was not updated to reflect the patient’s current medications. 2. Review of Patient 7's clinical record was initiated on 5/4/23. The clinical record showed the SOC was 6/21/22. The patient was certified for home health services during the certification period from 8/20/22 to 10/18/22. The Medication Profile showed the patient’s medications included tramadol (narcotic) 50 mg PO half tablet to one tablet QID PRN and acetaminophen (analgesic) 325 mg two tablets PO Q six hours PRN. However, there was no documented evidence showing the specific indications for the PRN medications and when to administer a half versus one tablet of tramadol. On 5/9/23 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to assess the PCG’s competency related to the wound care management for one of eight sampled patients (Patient 7). This failure created the risk for the patient not receiving the appropriate wound care which could lead to infections. Findings: Review of Patient 7's clinical record was initiated on 5/4/23. The clinical record showed the SOC was 6/21/22. The patient was certified for home health services during the certification period from 8/20/22 to 10/18/22. The POC, for the certification period from 8/20/22 to 10/28/22, showed for the PCG to perform the wound care on the non-SN visit days. Review of the Recertification OASIS dated 8/15/22, showed a section to indicate whether the patient/caregiver/family was knowledgeable and able to verbalize and/or demonstrate independence with wound care. However, review of this section showed the SN placed a check mark next to “not applicable.” There was also no documented evidence the SN had assessed the PCG’s competency related to wound care. Review of the Nursing Progress Note dated 8/23/22, showed the SN had placed a check mark indicating wound care instructions was provided to the patient/caregiver. However, there was no documented evidence showing the SN had assessed the PCG’s competency related to wound care. On 5/9/23 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

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: Based on interview and record review, the agency failed to ensure the POC included specific information related to the medication administration for one of eight sampled patients (Patient 1). This failure created the risk of not providing necessary services for this patient. Findings: Review of Patient 1's clinical record was initiated on 5/2/23. The clinical record showed the SOC was 11/14/22. The patient was certified for home health services during the certification period from 3/14/23 to 5/12/23. The recertification assessment dated 3/10/23, showed not applicable was documented for the question asking if the patient/PCG/family was knowledgeable and able to verbalize and/or demonstrate independence with injected medication administration. The POC, for the certification period from 3/14/23 to 5/12/23, showed the medication included epoetin alfa-epbx (used to treat severe anemia) 10,000 units/ml injection 1 ml under the skin three times a week when available. * However, there was no documented evidence who will be responsible to administer epoetin alfa-epbx once available. On 5/9/23 at 1004 hours, a concurrent interview and clinical record review was conducted with LVN 1. He was informed and acknowledged the findings.

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 observation, interview, and record review, the agency failed to coordinate the care to meet the patients' care needs for two of eight sampled patients (Patients 1 and 4). This failure created the risk of not providing necessary services for these patients. Findings: 1. Review of Patient 1's clinical record was initiated on 5/2/23. The clinical record showed the SOC was 11/14/22. The patient was certified for home health services during the certification period from 3/14/23 to 5/12/23. The POC, for the certification period from 3/14/23 to 5/12/23, showed the medication included epoetin alfa-epbx (used to treat severe anemia) 10,000 units/ml injection 1 ml under the skin three times a week when available. Documentation showed the medication was still not available and waiting for insurance approval. The Communication Note dated 3/23/23, showed a report was received from the LVN that the medication was still not available. Documentation showed the PCG was waiting for the pharmacy to call and to let the PCG know when the medication would be available for pick up. Documentation showed the physician was aware and notified. Documentation showed, "Will check again next week." * However, at the time of clinical record review, there was no documented evidence the HHA had coordinated with the PCG and physician about the status of the medication after the communication note dated 3/23/23. On 5/9/23 at 1004 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS and LVN 1. The Administrator/DPCS stated the patient was discharged yesterday (5/8/23). The Administrator/DPCS stated the insurance did not approve the medication. They were informed of the findings. 2. Review of Patient 4's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/10/23. The patient was certified for home health services during the certification periods from 1/10/23 to 3/10/23 and 3/11/23 to 5/9/23. The Medication Profile for the certification period from 3/11/23 to 5/9/23, showed the medications included gabapentin (anticonvulsant) 300 mg two capsules PO TID, vitamin D3 (supplement) 50 mcg one tablet PO QD, and vitamin B12 (supplement) 500 mcg one tablet PO QD. A joint home visit with RN 1 was conducted on 5/3/23 at 1000 hours, to Patient 4's home. Review of the patient’s medications with the patient and RN 1 was conducted. The patient stated he had been taking gabapentin 300 mg three capsules BID for years and the physician was aware. In addition, the medication bottle of vitamin D3 showed an expiration date of 2/23, and the medication bottle of vitamin B12 showed an expiration date of 6/22. * The HHA failed to coordinate with the physician regarding the patient's gabapentin. In addition, there was no documented evidence the agency had coordinated with the patient regarding the use of expired medications. On 5/9/23 at 1010 hours, an interview and concurrent clinical record review was conducted with LVN 1. He was informed and acknowledged the findings.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the SN had provided education to the patient/PCG related to the patient’s medication as per the POC for one of eight sampled patients (Patient 8), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 8's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/25/23. The patient was certified for home health services during the certification periods from 1/25/23 to 3/25/23 and 3/26/23 to 5/24/23. The POC, for the certification period from 1/25/23 to 3/25/23, cited SN visits daily for six days then 1W8 (one visit a week for eight weeks) to teach/instruct/train the patient/PCG regarding disease process/management/complications and medication regimen. The Medication Profile, for the certification period from 1/25/23 to 3/25/23, included prednisolone acetate (corticosteroid) 1% place one drop into the right eye for 14 days. Documentation showed the medication was discontinued on 2/8/23. The SN note dated 2/15/23, showed the patient/PCG was educated about the prednisolone medication. Documentation showed the medication was used to reduce irritation, redness, burning, and swelling of eye inflammation by changing the way the immune system works. Documentation showed the patient was instructed to continue taking the medication as prescribed by the physician and to notify if side effects become bothersome and persistent. * However, the medication had been discontinued on 2/8/23, after the patient/PCG education was provided on 2/15/23. On 5/9/23 at 0958 hours, an interview and concurrent clinical record review was conducted with LVN 1. He was informed and acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the visit schedules for three of eight sampled patients (Patients 3, 4, and 5). This failure created the risk of not providing the necessary information to the patients. 2. Review of Patient 4's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/10/23. The patient was certified for home health services during the certification periods from 1/10/23 to 3/10/23 and 3/11/23 to 5/9/23. The POC, for the certification period from 3/11/23 to 5/9/23, showed SN visits 2W1 and 1W7. A joint home visit with RN 1 was conducted on 5/3/23 at 1000 hours, to Patient 4's home. Review of the patient's home folder provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 5/9/23 at 1010 hours, an interview and clinical record review was conducted with LVN 1. He was informed and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 4/26/23. The patient was certified for home health services during the certification period from 4/26/23 to 6/24/23. The POC, for the certification period from 4/26/23 to 6/24/23, showed SN visits 2w2 and 1w7; and PT evaluation and set-up treatment plan. The physician’s order dated 4/28/23, showed PT evaluation done today (4/28/23) and provided with frequency of 1W1 and 2W3. A joint home visit with PT 1 was conducted on 5/4/23 at 1000 hours, to Patient 5's home. Review of the patient's home folder provided by the HHA showed no documented evidence of the written instructions outlining the SN and PT visit schedule. On 5/9/23 at 0954 hours, an interview and clinical record review was conducted with LVN 1. He was informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/17/23. The patient was certified for home health services during the certification period from 3/18/23 to 5/16/23. The POC, for the certification period from 3/18/23 to 5/16/23, cited SN visits 2W1 and 1W7. On 5/3/23 at 1210 hours, a joint home visit was conducted with LVN 1 to Patient 3’s home. Review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedules. On 5/3/23 at 1240 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 was asked to show the written instructions outlining the SN visit schedules. LVN 1 verified he did not provide written instructions to the patients. LVN 1 stated he only called the patients to confirm the visit schedule prior to visiting the patient’s home.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to implement infection control practices related to hand hygiene and the use of a medical equipment for one of eight sampled patients (Patient 3). This failure had the potential to spread the risk of infection. Findings: According to CDC, the Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient’s immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal Review of the agency’s P&P titled Bag Technique dated January 2004 showed when the visit is completed, reusable equipment will be cleaned using alcohol, soap, and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. Review of Patient 3's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/17/23. The patient was certified for home health services during the certification period from 3/18/23 to 5/16/23. Review of the Physician Order dated 4/20/23, showed to clean the left plantar first toe diabetic foot ulceration with dermal wound cleanser, pat dry with a gauze sponge, apply tetracyte (topical antibiotic) and hydrogel (gel that increases moisture within the wound) to the wound bed, followed by an impregnated gauze. After cover with a hydrocolloid dressing (dressing that keeps the wound moist) three times a week, use bordered gauze in between hydrocolloid dressing intervals. On 5/3/23 at 1210 hours, a joint home visit was conducted with LVN 1 to Patient 3’s home. LVN 1 used hand sanitizer and donned a new pair of gloves prior to assessing the patient. LVN 1 used the blood pressure cuff, pulse oximeter, thermometer, and stethoscope to assess the patient. After the assessment, LVN 1 returned the medical equipment in his bag without cleaning or sanitizing them. Prior to performing wound care, LVN 1 used the hand sanitizer and donned a new pair of gloves. LVN 1 took the old dressing off the patient’s toe and cleaned the wound three times using the dermal wound cleanser and gauze. After cleaning the wound, LVN 1 discarded the gloves and donned a new pair of gloves without washing his hands or using the hand sanitizer in between. LVN 1 then proceeded to apply the wound treatment as ordered. On 5/3/23 at 1245 hours, an interview was conducted with LVN 1. LVN 1 was informed of the observations and acknowledged the findings.

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 interview and record review, the agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, and control, creating the risk of the spread of infections. 4. Review of the agency’s infection control and QAPI program for 2022 and 2023 was conducted on 5/8/23. The infection control program for 2022 and 2023 showed the agency had collected, tracked, and trended the total infection occurrences for the patients. However, further review of the infection control program showed no documented evidence the agency had analyzed each type of infection. For example, review of the 2022 Quality Assessment and Performance Improvement Summary and Infection Control Logs showed the following: -There was an increase of COVID-19 infections from the first quarter to the third quarter. The first quarter showed there was one patient with COVID-19, second quarter had three, and the third quarter had four. -There was an increase of urinary infections from the third quarter to the fourth quarter. During the third quarter, there were two patients with urinary infections and the fourth quarter showed there were four patients. However, review of the Quality Assessment and Performance Improvement Summaries for 2022 showed the agency only analyzed the total number of infections per quarter. There was no documented evidence showing the agency had analyzed each type of infection to determine its causes. On 5/9/23 at 1029 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. Review of the agency's P&P titled Evaluating and Maintaining Records of Infections Among Patients dated 01/2004, showed in part: - All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery. If trends are discovered, target surveillance or problem-oriented surveillance may be initiated for specific high-risk patient populations if high volume, problem-prone areas are identified. - The Infection Identification-Patient Report Form is completed when any of the following occur: a. A new, actual, or suspected infection is clinically observed by home health personnel b. Culture is ordered and performed, and the results are positive c. A new antibiotic is ordered d. A patient is admitted to a hospital due to an actual or suspected infection e. An unanticipated death due to an actual or suspected infection f. A major permanent loss of function associated with an actual or suspected infection g. A reportable, communicable infection is identified h. Patient has temperatures greater than 101 degrees F i. Patient has conjunctivitis - The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection. - Each section of the report should be completed in its entirety. - If patient was admitted to home care from a hospital and a new infection was identified by the clinician within the first 48 hours of service, the source of the suspected infection may be nosocomial. - After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up. - The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The break down and summary may include, but will not be limited to: a. Number of infection types b. Sources of infection c. Diagnoses d. Age/sex of patients e. Family/caregiver f. Pathogens, if identified g. Follow-up taken - The Performance Improvement Coordinator, in conjunction with the Clinical Supervisor, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations. - A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the Professional Advisory Committee. Information from the summary, analysis, and discussion will be used to improve patient care. On 5/8/23 at 1312 hours, an interview was conducted with the Administrator/DPCS, CEO, and QA RN. The CEO stated the RN would fill out the individual infection report. The CEO stated she would summarize the infection control data quarterly. The CEO stated the electronic system would generate the quarterly report, the QA RN and DPCS would analyze the data during the quarterly QAPI meeting, and recommendation would be done by the QAPI committee. 1. Review of the agency's 2019 Infection Control and QAPI documents was conducted on 5/8/23. The agency failed to ensure the infection control data reported to the QAPI was consistent, the infection control data was analyzed based on the type of infection, and implemented specific action plan. For example: The second quarter 2019 Infection Control Log showed three cases of infection (one case of left toe wound and one case of “BILATERAL TOES” for April, one case of UTI for May and no infection case for June). The third quarter 2019 Infection Control Log showed five infection cases (one case of UTI and one case of foot wound infection for July, no infection case for August, and three cases of URIs for the month of September). The 2019 Third Quarter QAPI Summary dated 10/31/19, showed there was one infection reported for the quarter which decreased from the previous quarter. The infection reported was UTI. The action plan included instructing patients and PCG on infection control prevention measures such as hand washing, avoid people with infections, good perineal care, changing of incontinent pads, and keeping sin wound/ clean and dry always. * However, the number of infection cases reported to the QAPI was not consistent as there were five cases of infection documented in the third quarter Infection Control Log and one case of infection reported to the QAPI. There was no analysis on the types of infection, if the infection had decreased or not, as there was an increase in the cases of URI for the third quarter compared to the second quarter. There was no specific action plan developed for the increase in the URIs for the 2019 third quarter. 2. Review of the agency's 2020 Infection Control and QAPI documents was conducted on 5/8/23. The agency failed to ensure the infection control data reported to the QAPI was consistent, the infection control data was analyzed based on the type of infection, and implemented specific action plan. For example: The third quarter 2020 Infection Control Log showed three cases of infection (one infection case of COVID-19 and one infection case of acute cholecystitis for the month of July, one infection case of sacral pressure injury for the month of August, and no infection case for the month of September). The fourth quarter 2020 Infection Control Log showed three cases of infection (one case of pneumonia for October, one case of acute bronchitis for November, and one case of left foot cellulitis for December). The 2020 Fourth Quarter QAPI Summary dated 1/21/21, showed there was one infection reported for the quarter which remained the same from the previous quarter. The infection reported was left foot cellulitis. Documentation showed no further action needed at this time. However, the number of infection cases reported the QAPI was not consistent as there were three cases of infection documented in the fourth quarter infection Control Log and one case of infection reported to the QAPI. There was no analysis on the types of infection, if the infection had decreased or not, as there was an increase in the cases of respiratory infection for the fourth quarter 2020 compared to the third quarter. There was no specific action plan developed for the increase in the respiratory infection for the fourth quarter 2020. 3. Review of the agency's 2021 Infection Control and QAPI documents was conducted on 5/8/23. The agency failed to ensure the infection control data was analyzed consistently. For example: The fourth quarter 2020 Infection Control Log showed three cases of infection (one case of pneumonia for October, one case of acute bronchitis for November, and one case of left foot cellulitis for December). The first quarter 2021 Infection Control Log showed one case of infection (no infection case for the month of January and February, and one case of S/P skin graft procedure). The 2021 first Quarter QAPI Summary dated 4/29/21, showed there was one infection reported for the quarter which increased slightly from the previous quarter. * However, the analysis was not consistent as the analysis documented in the first Quarter QAPI Summary showed the infection cases slightly increased for the current quarter compared to the previous quarter. Wherein, there were three cases of infection documented in the fourth quarter 2020 Infection Control Log compared to one case of infection in the first quarter 2021 Infection Control Log. On 5/9/23 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. He was informed and acknowledged the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the care and services were provided in accordance with the POC for two of eight sampled patients (Patients 2 and 8). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. 2. Review of Patient 2's clinical record was initiated on 5/2/23. The clinical record showed the SOC was 2/15/23. The patient was certified for home health services during the certification period from 4/16/23 to 6/14/23. Review of the Physician Orders dated 4/16/23 cited OT visits 2W3 and 1W1. Review of the OT Visit Notes showed the OT only visited the patient on 5/6/23. There was no documented evidence showing the OT made an additional visit to the patient’s home for Week 3 (4/30/23 to 5/6/23) as cited in the order. On 5/9/23 at 0930 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 1. Review of Patient 8's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/25/23. The patient was certified for home health services during the certification periods from 1/25/23 to 3/25/23 and 3/26/23 to 5/24/23. The POC, for the certification period from 3/26/23 to 5/24/23, cited SN visits 2W1 and 1W8 to obtain oxygen saturation level via pulse oximetry Q visit and to notify the physician if oxygen level was below 90%. The SN note dated 3/28 and 3/31/23, showed no documented evidence oxygen saturation was obtained. On 5/9/23 at 0958 hours, an interview and clinical record review was conducted with LVN 1. He was informed and acknowledged the finding.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared the accurate and complete clinical notes for three of eight sampled patients (Patients 2, 4, and 7). This failure created the increased risk of substandard healthcare outcomes to these patients. 3. Review of Patient 4's clinical record was initiated on 5/3/23. The clinical record showed the SOC was 1/10/23. The patient was certified for home health services during the certification periods from 1/10/23 to 3/10/23 and 3/11/23 to 5/9/23. The POC, for the certification period from 1/10/23 to 3/10/23, cited SN visit 2W2 and 1W7 to monitor BS level via fingerstick Q visit. The SN note dated 1/19/23, showed the patient’s random BS was 198 mg/dl. Documentation showed on the narrative section of the form the patient refused BS at this time and requested for BS to be checked next week, which was not consistent as there was a BS level documented on the note. On 5/9/23 at 1010 hours, an interview and clinical record review was conducted with LVN 1. He was informed and acknowledged the finding. 1. Review of Patient 2's clinical record was initiated on 5/2/23. The clinical record showed the SOC was 2/15/23. The patient was certified for home health services during the certification period from 2/15/23 to 4/15/23. The POC, for the certification period from 2/15/23 to 4/15/23, cited OT evaluation and to set up the treatment plan. Review of the Physician Orders dated 3/1/23 showed the OT evaluation was completed and the frequency was 1W1, 2W2, and 1W1. Review of the Communication Note dated 3/1/23 showed the PT evaluation was completed. However, review of the POC showed no documented evidence the physician ordered PT evaluation. On 5/9/23 at 0930 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked to clarify the communication note. The Administrator/DPCS verified the patient did not have an order for PT treatment and stated it may have been a typographical error. 2. Review of Patient 7's clinical record was initiated on 5/4/23. The clinical record showed the SOC was 6/21/22. The patient was certified for home health services during the certification period from 8/20/22 to 10/18/22. The POC, for the certification period from 8/20/22 to 10/8/22, showed the patient had Stage 2 pressure ulcers to the left and right buttocks. The POC also showed the patient’s nutritional requirements included controlled carbohydrates, low salt, low fat, and low cholesterol. Review of the Recertification OASIS dated 8/15/22 showed the SN did not document the patient’s number of unhealed Stage 2 pressure ulcers. In addition, the SN also placed a check mark to indicate the patient had a no added salt diet instead of a low salt diet as cited in the POC. On 5/9/23 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written assignment for CHHA was accurately prepared by the RN for one of eight sampled patients (Patient 1), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 1's clinical record was initiated on 5/2/23. The clinical record showed the SOC was 11/14/22. The patient was certified for home health services during the certification period from 3/14/23 to 5/12/23. The POC, for the certification period from 3/14/23 to 5/12/23, cited CHHA visits 2W8 and 1W1 to assist the patient with bed bath, hygiene/grooming, positioning, and light housekeeping. * However, further review of the clinical record showed no documented evidence of the CHHA Care Plan prepared by the RN for the certification period from 3/14/23 to 5/12/23. On 5/9/23 at 1004 hours, an interview and clinical record review was conducted with the CEO and LVN 1. The CEO stated there was a CHHA care plan for the certification period from 3/14/23 to 5/12/23; however, the RN forgot to change the date to the current certification period which was 3/14/23 to 5/12/23, in the CHHA care plan. They were informed of the above findings.

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 interview and record review, the agency's Administrator failed to ensure responsibility for the day-to-day operations of the agency as evidenced by: * The agency failed to ensure the written agreements for four of the seven contractors (Contractors 1, 2, 3, and 4) included the required elements in the contracts related to discharge planning as per Title 22. * The agency failed to update the P&Ps related to the wound care assessments and discharge summaries. * The agency failed to ensure the personnel file included a job signed description and performance evaluation as per the agency’s P&P for one of six employees (LVN 2). * The agency failed to ensure PPD interpretation was documented as per the agency’s P&P for one of six employees (CHHA 1). These failures had the potential to negatively impact the agency’s operational performance. 3. The P&P titled Performance Evaluations undated, showed a performance evaluation will be conducted for all employees after three months of employment and at least annually thereafter on the employee’s anniversary hire date. The P&P titled Personnel Records undated, showed personnel files will be established and maintained for all personnel. The personnel record for an employee will include but not limited to a signed job description. Review of the personnel records was conducted on 5/4/23. LVN 2 was hired on 7/14/22. However, there was no documented evidence of a job signed description and performance evaluation after three months of employment as per the agency’s P&P. On 5/9/23 at 0930 hours, an interview and clinical record review was conducted with the CEO. She was informed and acknowledged the finding. 4. The P&P titled Health Screening undated showed each employee having direct contact with clients must have documentation of baseline health screening prior to providing care to clients. This includes, at a minimum, TB skin testing via Mantoux method. This testing includes the preplacement evaluation, administration, and interpretation of TB Mantoux skin tests and periodic evaluation. Review of the personnel records was conducted on 5/4/23. CHHA 1 was hired on 9/9/22. Documentation showed PPD was performed on 6/15/22 on CHHA 1’s right forearm. However, there was no documented evidence of the interpretation of the PPD performed on 6/15/22 as per the agency’s P&P. On 5/9/23 at 0930 hours, an interview and clinical record review was conducted with the CEO. She was informed and acknowledged the finding. Review of the agency’s Administrator job description showed the Administrator ensures quality and safe delivery of home health care services; coordinates services that reflect the agency’s philosophy and standards of care; and plans, develops, implements, and evaluates agency services, programs, and activities. 1. According to Title 22 Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the role, if any, of the agency and the contracted individual or agency in the discharge planning. Review of the written agreements between the agency and Contractors 1, 2, 3, and 4 was initiated on 5/4/23. The written agreements did not include the role, if any, of the agency and the contractors in the discharge planning. On 5/9/23 at 1006 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS and CEO. Both were informed and acknowledged the finding. 2a. Review of the agency’s P&P titled Discharge Summary (undated) showed when a client is discharged from the agency, a discharge summary form shall be completed by the registered nurse or therapist. A copy will be mailed to the physician upon request. The agency did not update the P&P to show that a copy of the completed discharge summary must be sent to the physician within five business days as cited in the regulation. b. On 5/9/23 at 1015 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked how often the SNs should be measuring the patient’s wounds. The Administrator/DPCS replied the SNs should be measuring the wound every dressing change. Review of the agency’s P&P titled Assessment/Staging of Pressure Ulcers (undated) showed in assessing the pressure ulcer, the following parameters should be addressed consistently: site, stage of ulcer, and size of ulcer (including length, width, and depth). The policy was not updated to show wounds must be measured every dressing change as stated by the Administrator/DPCS. On 5/9/23 at 1015 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge summary had all of the required elements related to the medications for one of eight sampled patients (Patient 6). This failure created the risk of providing substandard care to this patient as their clinical information was not complete. Findings: Review of Patient 6's closed clinical record was initiated on 5/3/23. The clinical record showed the SOC was 2/25/23. The patient was certified for home health services during the certification period from 2/25/23 to 4/25/23. The patient was discharged on 4/18/23. Review of the Discharge Summary dated 4/18/23, showed the summary of care provided. However, there was no documented evidence showing the patient's medications taking at the time of discharge. On 5/9/23 at 0951 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.