Every finding on record at The Trend Group Corporation

A Complaint Survey for complaint #2021005087, was conducted from April 12, 2021 to April 13, 2021(onsite) and continued from April 14, 2021 to April 23, 2021 (offsite) at Trend Home Health Services. The Home Health Agency was not in compliance with 42 CFR 484 Subpart A-C requirements for Home Health Agencies.

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to establish a written agreement with the patient or the patient's legal representative specifying the sources of payment for 2 out of 7 Sampled Patients (SP). SP#2 and SP#3 Findings include: Review of SP#2's record revealed she was admitted on 02/16/2021. Further review of SP#2's client service agreement revealed the agency's personnel did not document the source of payment for the services, the discipline that would provide the services nor the frequency of the services to be provided. During an interview conducted on 04/12/2021 at 1:45 PM, the Administrator reviewed SP#2's record and acknowledged that the agency did not document the source of payment, the discipline that would provide the services nor the frequency of the services to be provided on SP#2's service agreement on 02/16/2021. During an interview conducted on 04/13/2021 at 2:00 PM, the Director of Nursing and the Administrator reviewed SP#2's record and acknowledged the above findings. Record review revealed SP#3 was admitted on 02/25/2021 to receive HHA services from the agency. Further review of SP#3's record revealed the agency established a service agreement with the patient on 03/12/2021 which is 15 days after the initial admission. Further review of SP#3's client service agreement revealed the agency's staff did not document the source of payment for the services. During an interview conducted on 04/13/2021 at 2:09 PM, the Director of Nursing and the Administrator reviewed SP#3's record and acknowledged that the agency did not establish a service agreement with SP#3 on 02/25/2021. Furthermore, the DON acknowledged that the agency's personnel did not document the source of payment for the services on SP#3's service agreement dated 03/12/2021.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that the patient participated in, be informed about, and consent or refuse care in advance of providing care to 1 out of 3 Sampled Patients (SP). SP#5 Findings include: Review of SP#5's record revealed she was admitted on 02/16/2021. Further review of SP#5's record revealed no documentation that the agency completed the admission documents nor established a written agreement with the patient on 02/16/2021. A review of the agency's policy and procedure manual revealed a form titled "Client Bill of Rights/Responsibilities" which contained the following: "Policy: Home Health Care Agency staff members implement the Client's Bill of Rights and Responsibilities. The Client Bill of Rights statement and other written admission documents, Advance Directives information, written information concerning our policies on Advance Directives, are provided to the client or the client's representative prior to the start of care or at the time of initiation of care." During an interview conducted on 04/12/2021 at 2:43 PM, the Administrator acknowledged that SP#5's record did not contain documentation to demonstrate that the agency completed the admission documents nor established a written agreement with the patient on 02/16/2021.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the Home Health Agency failed to investigate the allegation made by 1 out of 7 Sampled Patients (SP)'s relative. SP#1 Findings include: A review of the agency's complaint log binder conducted on 04/12/2021 at 10:13 AM revealed a complaint report dated 04/05/2021 which contained the following: "Patient's son contacted case manager to report that his mother's arm was fractured." Further review of the complaint log binder and the complaint report dated 04/05/2021 revealed no documentation that the Director of Nursing (DON)/ Administrator contacted SP#1's relative nor investigated his allegation as of 04/12/2021. On 04/12/2021 at 10:30 AM, the surveyor requested SP#1's record for review from the Administrator. On 04/12/2021 at 11:10 AM, the Administrator provided SP#1's record and stated that it was complete. Review of SP#1's record revealed she was admitted on 02/01/2019. Further record review revealed SP#1 received Home Health Aide (HHA) services daily from the agency. Additional review of SP#1's record revealed that Staff A provided HHA services to the patient on 03/31/2021, 04/01/2021 and 04/02/2021. Continued review of SP#1's record revealed no documentation that the DON/ Administrator contacted SP#1's relative concerning his allegation or the patient's health/medical status after he reported the incident on 04/05/2021. Further review of SP#1's record revealed no documentation that the DON/ Administrator investigated SP#1's allegation as of 04/12/2021. During an interview conducted on 04/12/2021 at 12:03 PM, the Administrator acknowledged that the complaint log binder/ complaint report dated 04/05/2021 and SP#1's record did not contain documentation to demonstrate that he or the DON contacted SP#1's relative nor investigated his allegation as of 04/12/2021. During an interview conducted on 04/13/2021 at 1:21 PM, the DON acknowledged that SP#1's record did not contain documentation to demonstrate that she contacted SP#1's relative to find out what transpired on 04/02/2021, nor to inquire about SP#1's health/medical status. Furthermore, the DON also acknowledged that Staff A's personnel file did not contain documentation to demonstrate that she addressed the incident with the employee nor reeducated/reassessed her competency skills as of 04/13/2021.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to furnished services for 3 out of 7 Sampled Patients' (SP) SP#1, SP#6, and SP#7. Findings include: Review of SP#1's record revealed she was admitted on 02/01/2019. Further record review revealed SP#1 received Home Health Aide (HHA) services from the agency. Additional review of SP#1's record revealed no documentation that the agency provided the HHA services to SP#1 on 03/27/2021, 03/28/2021, 03/29/2021, 03/30/2021, 04/03/2021, 04/04/2021 and 04/05/2021. Continued review of SP#1's record revealed no missed visits documentation for 03/27/2021, 03/28/2021, 03/29/2021, 04/03/2021, 04/04/2021 and 04/05/2021. During an interview conducted on 04/12/2021 at 1:30 PM, the Administrator acknowledged that the agency did not provide the HHA services to SP#1 on 03/27/2021, 03/28/2021, 03/29/2021, 04/03/2021, 04/04/2021 and 04/05/2021. The Administrator also acknowledged that SP#1's record did not contain any documentation to explain why the services were not provided to the patient. A review of the agency's policy manual revealed a form titled "Director of Nursing Job Description" revealed the following: "Director of Nursing Clinical Manager Oversight: The director of nursing shall establish a process to verify that skilled nursing and personal care services were provided." During an interview conducted on 04/12/2021 at 4:49 PM, the patient's relative stated that the agency did not provide the HHA services to SP#1 on 03/27/2021, 03/28/2021/ 03/29/2021 and 03/30/2021 because Staff B tested positive for Covid-19 and they could not find another HHA. SP#1's relative stated that when he found out that Staff B tested positive for Covid-19 on 03/26/2021, he ensured that he, SP#1 and his spouse got tested and they were all negative. SP#1's relative that the Director of Nursing/ Administrator did not follow up with him/ SP#1 to find out if the patient was asymptomatic/ symptomatic or if she had gotten tested after Staff B tested positive for Covid-19. Furthermore, SP#1's relative stated that on Saturday (04/03/2021) and Sunday (04/04/2021), the patient's relative stated that he called the agency more than a dozen times to request an HHA for the weekend, however the agency's staff was unreachable, and no one returned his calls the entire weekend; and the agency did not provide the HHA services to SP#1 on 04/05/2021. Review of SP#6's record revealed he was admitted on 02/02/2018 to receive HHA services. Further review of SP#6's record revealed no documentation that the agency provided the HHA services on 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. Additional review of SP#6's record revealed no missed documentation for 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. During an interview conducted on 04/13/2021 at 11:13 AM, SP#6's relative stated that the agency has not been providing all the hours to the patient and they have been unable to provide the HHA services on Sundays. SP#6 relative stated that the agency did not provide the HHA services four consecutive Sundays (03/21/2021, 03/28/2021, 04/04/2021, and 04/11/2021). Furthermore, SP#6's relative stated that no one from the agency called or showed up this past Saturday (04/10/2021), therefore his relative who has her own medical issues is forced to take care of SP#6 when the agency does not send an HHA to provide the services. During an interview conducted on 04/13/2021 at 1:42 PM, the DON reviewed SP#6's record and acknowledged that the agency did not provide the HHA services to SP#6 on 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. The DON stated, "I know they tried diligently to staff the case. What I have to do is send the patients a letter to let them know to ask for me directly when they have a concern." Review of SP#7's record revealed she was admitted on 07/01/2020 to receive HHA services. Further review of SP#7's record revealed the agency did not provide the HHA services on 03/07/2021 and 03/08/2021. During an interview conducted on 04/13/2021 at 1:45 PM, the DON reviewed SP#7's record and acknowledged that the agency did not provide the HHA services to SP#7 on 03/07/2021 and 03/08/2021; the DON stated, "There was no coverage, I didn't see any missed visits or coverage on the HHA exchange."

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the Home Health Agency failed to coordinate care delivery to assess 1 out of 7 Sampled Patients (SP) after the patient's relative alleged that a Home Health Aide (HHA) injured the patient. SP#1 Findings include: A review of the agency's complaint log binder conducted on 04/12/2021 at 10:13 AM revealed a complaint report dated 04/05/2021 which contained the following: "Patient's son contacted case manager to report that his mother's arm was fractured." Further review of the complaint log binder and the complaint report dated 04/05/2021 revealed no documentation that the Director of Nursing (DON)/ Administrator contacted SP#1's relative nor investigated his allegation as of 04/12/2021. On 04/12/2021 at 10:30 AM, the surveyor requested SP#1's record for review from the Administrator. On 04/12/2021 at 11:10 AM, the Administrator provided SP#1's record and stated that it was complete. Review of SP#1's record revealed she was admitted on 02/01/2019. Further record review revealed SP#1 received Home Health Aide (HHA) services daily from the agency. Additional review of SP#1's record revealed Staff A provided HHA services to the patient on 03/31/2021, 04/01/2021 and 04/02/2021. Continued review of SP#1's record revealed no documentation that the DON or a Registered Nurse (RN) assessed SP#1 after the patient's relative alleged that Staff A injured the patient. The patient's relative stated that he called the agency more than a dozen times on Saturday (04/03/2021) and Sunday (04/04/2021) to report the incident and to request Home Health Aide coverage for the weekend, however the agency was unreachable, and the agency's personnel did not follow up with him nor returned his calls. Review of the clinic's medical record dated 04/03/2021 1149 revealed the following "X-ray shoulder left 2+ views (Final result); Left shoulder: Standard views are obtained. There is a comminuted fracture in the neck and proximal humeral shaft. There is medial and anterior angulation at the level of the shaft component with medial displacement of the distal shaft component. There is a roughly triangular isolated comminuted component along the lateral posterior aspect of the main fracture site. Impression: Comminuted fracture humeral neck and proximal humeral shaft as discussed." Further review of page 3 of SP#1's medical record dated 04/03/2021 revealed the following: "Patient arrived to clinic by Wheelchair mode, and patient's history was provided by self accompanied by son." Additional review of page 6 of the medical record revealed the following: "Neurological: Mental status: She is alert and oriented to person, place and time." Further record review revealed a policy titled "Director of Nursing job description" which contained the following "Duties and responsibilities: (a) The Director of Nursing of the Home Health Agency shall: 3. Coordinate patient care services." During an interview conducted on 04/13/2021 at 1:18 PM, the DON acknowledged that SP#1's record did not contain documentation to demonstrate that she coordinated care delivery to assess SP#1 after she became aware of the patient's relative allegation that Staff A injured the patient. The DON stated that she wanted to send an RN to assess SP#1 and to find out from the patient's relative what transpired on 04/02/2021. On 04/13/2021 at 1:21 PM, the DON stated that she did not send an RN to assess SP#1 because she was admitted to hospice on Monday April 5th, 2021. Furthermore, the DON stated that she did not contact SP#1's relative to find out what transpired on 04/02/2021 nor to inquire about SP#1's health/ medical status.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, interview, the Home Health Agency failed to coordinate care delivery for 3 out 7 Sampled Patients (SP). SP#1, SP#6, and SP#7 Findings include: Review of SP#1's record revealed she was admitted on 02/01/2019. Further record review revealed SP#1 received Home Health Aide (HHA) services from the agency. Additional review of SP#1's record revealed no documentation that the agency provided the HHA services to SP#1 on 03/27/2021, 03/28/2021, 03/29/2021, 03/30/2021, 04/03/2021, 04/04/2021 and 04/05/2021. Continued review of SP#1's record revealed no missed visits documentation for 03/27/2021, 03/28/2021, 03/29/2021, 04/03/2021, 04/04/2021 and 04/05/2021. During an interview conducted on 04/12/2021 at 1:30 PM, the Administrator acknowledged that the agency did not provide the HHA services to SP#1 on 03/27/2021, 03/28/2021, 03/29/2021, 04/03/2021, 04/04/2021 and 04/05/2021. The Administrator also acknowledged that SP#1's record did not contain any documentation to explain why the services were not provided to the patient. During an interview conducted on 04/12/2021 at 4:49 PM, the patient's relative stated that the agency did not provide the HHA services to SP#1 on 03/27/2021, 03/28/2021/ 03/29/2021 and 03/30/2021. The patient's relative stated Staff B tested positive for Covid-19 and they could not find another HHA. SP#1's relative stated that when he found out that Staff B tested positive for Covid-19 on 03/26/2021, he ensured that he, SP#1 and his spouse got tested and they were all negative. SP#1's relative stated that the Director of Nursing/ Administrator did not follow up with him/ SP#1 to find out if the patient was asymptomatic/ symptomatic or if she had gotten tested after Staff B tested positive for Covid-19. Furthermore, SP#1's relative stated that on Saturday (04/03/2021) and Sunday (04/04/2021), the patient's relative stated that he called the agency more than a dozen times to request an HHA for the weekend, however the agency's staff was unreachable, and no one returned his calls the entire weekend; and the agency did not provide the HHA services to SP#1 on 04/05/2021. A review of the agency's policy manual revealed a form titled "Director of Nursing Job Description" revealed the following: "Director of Nursing Clinical Manager Oversight: The director of nursing shall establish a process to verify that skilled nursing and personal care services were provided." Review of SP#6's record revealed he was admitted on 02/02/2018 to receive HHA services. Further review of SP#6's record revealed no documentation that the agency provided the HHA services on 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. Additional review of SP#6's record revealed no missed visits documentation for 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. During an interview conducted on 04/13/2021 at 11:13 AM, SP#6's relative stated that the agency has not been providing all the hours to the patient and they have been unable to provide the HHA services on Sundays. SP#6's relative stated that the agency did not provide the HHA services four consecutive Sundays (03/21/2021, 03/28/2021, 04/04/2021, and 04/11/2021). Furthermore, SP#6's relative stated that no one from the agency called or showed up this past Saturday (04/10/2021), therefore his mother who has her own medical issues is forced to take care of SP#6 when the agency does not send an HHA to provide the services. During an interview conducted on 04/13/2021 at 1:42 PM, the DON reviewed SP#6's record and acknowledged that the agency did not provide the HHA services to SP#6 on 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. The DON stated, "I know they tried diligently to staff the case. What I have to do is send the patients a letter to let them know to ask for me directly when they have a concern." Review of SP#7's record revealed she was admitted on 07/01/2020 to receive HHA services. Further review of SP#7's record revealed the agency did not provide the HHA services on 03/07/2021 and 03/08/2021. During an interview conducted on 04/13/2021 at 1:45 PM, the DON reviewed SP#7's record and acknowledged that the agency did not provide the HHA services to SP#7 on 03/07/2021 and 03/08/2021; the DON stated, "There was no coverage, I didn't see any missed visits or coverage on the HHA exchange."

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 record review and interview, the Home Health Agency failed to ensure a Registered Nurse (RN) or other appropriate skilled professional provided written patient care instructions for the Home Health Aide (HHA) to follow for 2 out of 3 Sampled Patients (SP). SP#2 and SP#3 Findings include: Record review revealed SP#2 was admitted on 02/16/2021 to receive HHA services from the agency. Further review of SP#2's record revealed no documentation that an RN or other appropriate skilled professional provided written patient care instructions for the HHA to follow concerning the patient. During an interview conducted on 04/13/2021 at 1:45 PM, the Director of Nursing reviewed SP#2's record and acknowledged that an RN or other appropriate skilled professional did not provide written patient care instructions for the HHA to follow concerning SP#2. Record review revealed SP#3 was admitted on 02/25/2021 to receive HHA aide services from the agency. Further review of SP#3's record revealed no documentation that an RN or other appropriate skilled professional provided written patient care instructions for the HHA to follow concerning the patient. During an interview conducted on 04/13/2021 at 1:47 PM, the Director of Nursing reviewed SP#3's record and acknowledged that an RN or other appropriate skilled professional did not provide written patient care instructions for the HHA to follow concerning SP#3.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the Home Health Agency failed to coordinate care delivery for 3 out 7 Sampled Patients (SP). SP#1, SP#6, and SP#7 Findings include: Review of SP#1's record revealed she was admitted on 02/01/2019. Further record review revealed SP#1 received Home Health Aide (HHA) services from the agency. Additional review of SP#1's record revealed no documentation that the agency provided the HHA services to SP#1 on 03/27/2021, 03/28/2021, 03/29/2021, 03/30/2021, 04/03/2021, 04/04/2021 and 04/05/2021. Continued review of SP#1's record revealed no missed visits documentation for 03/27/2021, 03/28/2021, 03/29/2021, 04/03/2021, 04/04/2021 and 04/05/2021. During an interview conducted on 04/12/2021 at 1:30 PM, the Administrator acknowledged that the agency did not provide the HHA services to SP#1 on 03/27/2021, 03/28/2021, 03/29/2021, 04/03/2021, 04/04/2021 and 04/05/2021. The Administrator also acknowledged that SP#1's record did not contain any documentation to explain why the services were not provided to the patient. A review of the agency's policy manual revealed a form titled "Director of Nursing Job Description" revealed the following: "Director of Nursing Clinical Manager Oversight: The director of nursing shall establish a process to verify that skilled nursing and personal care services were provided." During an interview conducted on 04/12/2021 at 4:49 PM, the patient's relative stated that the agency did not provide the HHA services to SP#1 on 03/27/2021, 03/28/2021/ 03/29/2021 and 03/30/2021 because Staff B tested positive for Covid-19 and they could not find another HHA. SP#1's relative stated that when he found out that Staff B tested positive for Covid-19 on 03/26/2021, he ensured that he, SP#1 and his spouse got tested and they were all negative. SP#1's relative stated that the Director of Nursing/ Administrator did not follow up with him/ SP#1 to find out if the patient was asymptomatic/ symptomatic or if she had gotten tested after Staff B tested positive for Covid-19. Furthermore, SP#1's relative stated that on Saturday (04/03/2021) and Sunday (04/04/2021), he called the agency more than a dozen times to request an HHA for the weekend, however the agency's staff was unreachable, and no one returned his calls the entire weekend; and the agency did not provide the HHA services to SP#1 on 04/05/2021. Review of SP#6's record revealed he was admitted on 02/02/2018 to receive HHA services. Further review of SP#6's record revealed no documentation that the agency provided the HHA services on 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. Additional review of SP#6's record revealed no missed visits documentation for 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. During an interview conducted on 04/13/2021 at 11:13 AM, SP#6's relative stated that the agency has not been providing all the hours to the patient and they have been unable to provide the HHA services on Sundays. SP#1 relative stated that the agency did not provide the HHA services four consecutive Sundays (03/21/2021, 03/28/2021, 04/04/2021, and 04/11/2021). Furthermore, SP#6's relative stated that no one from the agency called or showed up this past Saturday (04/10/2021), therefore his mother who has her own medical issues is forced to take care of SP#6 when the agency does not send an HHA to provide the services. During an interview conducted on 04/13/2021 at 1:42 PM, the DON reviewed SP#6's record and acknowledged that the agency did not provide the HHA services to SP#6 on 03/21/2021, 03/28/2021, 04/04/2021, 04/10/2021 and 04/11/2021. The DON stated, "I know they tried diligently to staff the case. What I have to do is send the patients a letter to let them know to ask for me directly when they have a concern." Review of SP#7's record revealed she was admitted on 07/01/2020 to receive HHA services. Further review of SP#7's record revealed the agency did not provide the HHA services on 03/07/2021 and 03/08/2021. During an interview conducted on 04/13/2021 at 1:45 PM, the DON reviewed SP#7's record and acknowledged that the agency did not provide the HHA services to SP#7 on 03/07/2021 and 03/08/2021; the DON stated, "There was no coverage, I didn't see any missed visits or coverage on the HHA exchange."

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review, interview and record review, the Director of Nursing failed to provide oversight of all patient care services assuring that patient needs are continually assessed for 1 out 7 Sampled Patients (SP) after the patient's relative alleged that a Home Health Aide (HHA) injured the patient. SP#1 Findings include: A review of the agency's complaint log binder conducted on 04/12/2021 at 10:13 AM revealed a complaint report dated 04/05/2021 which contained the following: "Patient's son contacted case manager to report that his mother's arm was fractured." Further review of the complaint log binder and the complaint report dated 04/05/2021 revealed no documentation that the Director of Nursing (DON)/ Administrator contacted SP#1's relative nor investigated his allegation and complaint as of 04/12/2021. On 04/12/2021 at 10:30 AM, the surveyor requested SP#1's record for review from the Administrator. On 04/12/2021 at 11:10 AM, the Administrator provided SP#1's record and stated that it was complete. Review of SP#1's record revealed she was admitted on 02/01/2019. Further record review revealed SP#1 received Home Health Aide (HHA) services daily from the agency. Additional review of SP#1's record revealed Staff A provided HHA services to the patient on 03/31/2021, 04/01/2021 and 04/02/2021. Continued review of SP#1's record revealed no documentation that the DON or a Registered Nurse (RN) assessed SP#1 after the patient's relative alleged that Staff A injured the patient. Sample Patient #1's relative stated that he called the agency more than a dozen times on Saturday (04/03/2021) and Sunday (04/04/2021) to report the incident and to request Home Health Aide coverage for the weekend, however the agency was unreachable, and the agency's personnel did not follow up with him nor returned his calls. Review of the clinic's medical record dated 04/03/2021 revealed the following "X-ray shoulder left 2+ views (Final result); Left shoulder: Standard views are obtained. There is a comminuted fracture in the neck and proximal humeral shaft. There is medial and anterior angulation at the level of the shaft component with medial displacement of the distal shaft component. There is a roughly triangular isolated comminuted component along the lateral posterior aspect of the main fracture site. Impression: Comminuted fracture humeral neck and proximal humeral shaft as discussed." Further record review revealed a policy titled "Director of Nursing job description" which contained the following "Duties and responsibilities: (a) The Director of Nursing of the Home Health Agency shall: 3. Coordinate patient care services." During an interview conducted on 04/13/2021 at 1:18 PM, the DON acknowledged that SP#1's record did not contain documentation to demonstrate that she coordinated care delivery to assess SP#1 after she became aware of the patient's relative allegation that Staff A harmed the patient. The DON stated that she wanted to send an RN to assess SP#1 and to find out from the patient's relative what transpired on 04/02/2021. On 04/13/2021 at 1:21 PM, the DON stated that she did not send an RN to assess SP#1 because she was admitted to hospice on Monday April 5th, 2021. Furthermore, the DON stated that she did not contact SP#1's relative to find out what transpired on 04/02/2021 nor to inquire about SP#1's health/ medical status.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the Home Health Agency failed to ensure that 1 out 7 Sampled Patients (SP)'s record contained the admission documents and consent forms for the most recent home health admission. SP#5 Findings include: Review of SP#5's record revealed she was admitted on 02/16/2021. Further review of SP#5's record revealed no documentation that the agency completed the admission documents nor established a written agreement with the patient on 02/16/2021. A review of the agency's policy and procedure manual revealed a form titled "Client Bill of Rights/Responsibilities" which contained the following: "Policy: Home Health Care Agency staff members implement the Client's Bill of Rights and Responsibilities. The Client Bill of Rights statement and other written admission documents, Advance Directives information, written information concerning our policies on Advance Directives, are provided to the client or the client's representative prior to the start of care or at the time of initiation of care." During an interview conducted on 04/12/2021 at 2:43 PM, the Administrator acknowledged that SP#5's record did not contain documentation to demonstrate that the agency completed the admission documents nor established a written agreement with the patient on 02/16/2021.