Every finding on record at Trc Home Health Services LLC

Purpose of visit: Recertification Survey Entrance conference date 05/21/2025 The census was -112 Licensed and Certified patients – 112 Licensed Home Health patients – 0 Personal Assistant Services -0 The Agency is in compliance with emergency preparedness.

Purpose of visit: Recertification, relicensure survey and complaint investigation intake 1008808 and 384361 Entrance conference date 05/21/2025 The census was -112 Licensed and Certified patients – 112 Licensed Home Health patients – 0 Personal Assistant Services-0 Abbreviations: QIO- Quality Improvement Organization CMS- Centers for Medicare and Medicaid Services Adm- Administrator Alt Adm- Alternate Administrator DCS – Director of Clinical Services (Supervising Nurse/Director of Nurses) NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care PT- Physical Therapy PTA- Physical Therapy Assistant OASIS – Outcome and Assessment Information Set RN- Registered Nurse LVN- Licensed Vocational Nurse LPN- License Practical Nurse ADON- Alternate Director of Nurses QAPI- Quality Assurance and Performance Improvement PIP – Performance Improvement Project

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the agency failed to provide a written Notice of Medicare Non-Coverage (NOMNC) notice, in advance of the Home Health Agency’s termination of on-going care for 2 (Patients 11, and 12) of 5 discharge patients’ records reviewed. This failure prevented patients from exercising the right to dispute the termination of Medicare-covered services which potentially placed patients at risk of interruptions in care and services after discharge. Record review of Patient 11 revealed a Plan of Care (POC) for period 6/11/2024 to 08/09/2024 signed by PT B with physical therapy visits ordered twice a week for 4 weeks. Records contained an OASIS discharge visit with goals met, dated 07/03/2024 signed by PT B. Records did not contain a NOMNC (Medicare form used to notify beneficiaries when their Medicare-covered services for home health are ending and how to appeal the termination of services) discharge notice. Record review of Patient 12 revealed a POC for period 04/29/2024 to 06/27/2024 signed by RN B with nurse visits ordered once a week for 6 weeks. Records contained an OASIS discharge visit with goals met, dated 06/07/2024 signed by RN B. Records did not contain a NOMNC discharge notice. An interview was conducted with PT B on 06/03/2025 at 11:46 am. The surveyor asked about the agency’s policy on providing written patient discharge notification. PT B stated patients are provided a “5- day discharge notice. We have the patient sign it within five days before discharge.” The surveyor informed PT B of the missing NOMNC discharge notice for Patient 11 and asked why the agency’s policy was not followed. PT B stated, the NOMNC should have been provided during “the last visit that the PTA saw the patient…and attached to the physical therapy assistant’s visit note.” PT B further stated that she did not know why the NOMNC discharge notice form was not in the patient’s record. When asked about the potential patient outcome for not receiving the NOMNC discharge notice, PT B stated, patients “would not know the reasons they were being discharged.” Surveyor attempted a phone interview with PTA 1 on 06/03/2025 at 1:16 pm regarding the NOMNC discharge notice for Patient 11. Surveyor left a voicemail message to return call with contact information. An interview was conducted with RN B on 06/03/2025 at 12:42 pm. The surveyor asked about the agency’s policy on providing written patient discharge notification. RN B stated, “I give (provide) the patient the discharge notification papers five days before discharge and forward it to the agency through our secure email.” The surveyor informed RN B of the missing NOMNC discharge notice for Patient 12 and asked why the agency’s policy was not followed. RN B stated, she did not know why the NOMNC was not in the patient’s record. RN B stated “I can’t remember” if the NOMNC was provided to Patient 12. When asked about the potential patient outcome for not receiving the NOMNC discharge notice, RN B stated, “the patient would not be aware of the planned discharge.” An interview was conducted with the Adm and Alt Adm/DCS on 06/03/2025 at 2:23pm. The surveyor asked about the agency’s policy on providing patient written discharge notification. The Alt Adm/DCS stated, “there is a 2-day (NOMNC) and 5-day discharge notice given (provided) to the patients 5 days or more before discharge. All patients receive a notice unless discharge is requested by the patient. A copy is left with the patient and uploaded in the system (patient electronic medical record).” When asked who was responsible for providing the NOMNC written notice to patients who received physical therapy services only, the Alt Adm/DCS stated “the PTA or the physical therapist that followed the patient.” The surveyor informed the Adm and Alt Adm/DCS about the interviews with RN B and PT B on the missing written discharge notices for Patients 11, and 12. When asked why the agency’s policy was not followed the Alt Adm/DCS stated a Performance Improvement Project was written in April of 2025 on discharge notices not being completed and uploaded. The Alt Adm/DCS stated she “re-educated staff” on providing written discharge notices. The Alt Adm/DCS stated the majority of the agency’s patients were on service “for a short time, 2 to 3 weeks.” The Alt Adm/DCS stated the agency discussed planned patient discharges during the case conferences (meeting to discuss patient issues, share information and plan next steps in patient care) and agency staff were assigned to provide the written discharge notices. When asked about the potential patient outcome for not receiving the NOMNC discharge notices, the Alt Adm/DCS stated, “not understanding they (the patients) are being discharged” and the patients “can’t dispute the discharge if they are not ready.” Review of agency’s policy “Patient/Client Transfer, Discharge, and Agency Dissolution, PE.25,” revision 08/01/2020 reads in part “The Agency may only transfer or discharge the patient/client from the Agency if: The transfer or discharge is appropriate because the physician and/or non-physician practitioner who is responsible for the home health plan of care and the agency agree that the measurable outcomes and goals set forth in the plan of care have been achieved, and the Agency and the physician and / or non-physician practitioner who was responsible for the home health plan of care agree that the patient/client no longer needs the Agency’s services. Procedure: The Agency will provide notice to eligible patients/clients of the right to expedited determinations using the Notice of Medicare Non-Coverage (an OMB -approved Medicare form) when the period of covered care ends. Review of agency’s “Billing Process/Advance Beneficiary Notice/False Claims, RI.50,” revision 01/13/2018 reads in part “Patient/Client Goals Met-All care ending with the patient/client goals met or physician orders completed (NOMNC must be given).” Review of agency’s policy “Patient/Client Rights and Responsibilities, RI.5,” revision 05/01/2024 reads in part “The patient/client has the right to: Receive proper written notice…in advance of the Agency reducing or terminating on going care.”

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observations, record reviews and interviews the agency failed to provide the name, address, and phone number for the Agency on Aging and failed to provide the correct name and phone numbers for the Quality Improvement Organization (QIO) for 7 (Patients 1,2,3,4,5,6, and 7) of 12 active patients’ records reviewed. This failure potentially placed patients at risk for not receiving information, referrals, and community services through federally funded and state funded agencies. Record review of the Agency’s Home Health folder on 5/21/2025 revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 (former CMS contracted agency which received appeals from patients regarding home health discharge decisions) and did not show the July 1,2024 updated CMS contractor information and phone number for CA2 (contracted by CMS to receive appeals from patients regarding home health discharge decisions). Record review of Patient 1’s home health folder and interview with Patient 1 during a home visit on 5/27/2025 at 1:00pm revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 and did not include the updated CMS contractor information and phone number for CA2. Review of patient’s plan of care for period 03/23/2025-05/21/2025 showed a start of care date of 07/26/2024. When asked if any pages had been removed from the home health folder, Patient 1 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 1 stated “No.” Record review of Patient 2’s home health folder and interview with Patient 2 during a home visit on 5/27/2025 at 2:20 pm revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 and did not include the updated CMS contractor information and phone number for CA2. Review of patient’s plan of care for period 04/23/2025-06/21/2025 showed a start of care date of 04/23/2025. When asked if any pages had been removed from the home health folder, Patient 2 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 2 stated “No, I don’t believe so.” Record review of Patient 3’s home health folder and interview with Patient 3 during a home visit on 5/29/2025 at 2:55 pm revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 and did not include the updated CMS contractor information and phone number for CA2. Review of patient’s plan of care for period 04/22/2025-06/20/2025 showed a start of care date of 04/22/2025. When asked if any pages had been removed from the home health folder, Patient 3 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 3 stated “No.” Record review of Patient 4’s home health folder and interview with Patient 4 during a home visit on 5/28/2025 at 2:27 pm revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 and did not include the updated CMS contractor information and phone number for CA2. Review of patient’s plan of care for period 05/09/2025-07/07/2025 showed a start of care date of 05/09/2025. When asked if any pages had been removed from the home health folder, Patient 4 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 4 stated “No.” Record review of Patient 5’s home health folder and interview with Patient 5 during a home visit on 5/28/2025 at 4:00 pm revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 and did not include the updated CMS contractor information and phone number for CA2. Review of patient’s plan of care for period 05/12/2025-07/10/2025 showed a start of care date of 05/12/2025. When asked if any pages had been removed from the home health folder, Patient 5 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 5 stated “No, but my husband knows how to contact them (Agency on Aging and QIO).” Record review of Patient 6’s home health folder and interview with Patient 6 during a home visit on 5/28/2025 at 12:30 pm revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 and did not include the updated CMS contractor information and phone number for CA2. Review of patient’s plan of care for period 05/08/2025-07/06/2025 showed a start of care date of 05/08/2025. When asked if any pages had been removed from the home health folder, Patient 6 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 6 stated “No.” Record review of Patient 7’s home health folder and interview with Patient 7 during a home visit on 5/28/2025 at 11:49 am revealed an undated Community and State Information list with no contact information for the Agency on Aging. The Patient Information Booklet dated 01/13/2018 contained the outdated QIO Texas contact information for CA1 and did not include the updated CMS contractor information and phone number for CA2. Review of patient’s plan of care for period 04/16/2025-06/14/2025 showed a start of care date of 04/16/2025. When asked if any pages had been removed from the home health folder, Patient 2 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 2 stated “No, I don’t recall.” An interview was conducted with the Adm and Alt Adm/DCS on 5/22/2025 at 10:05 am. When asked, who was responsible for updating the Community and State Information list and Patient Information Booklet the Adm stated the patients’ home health folders were created and ordered from a home health consultant (a professional who provides expert advice or services). When asked about the outdated QIO information and missing contact information for the Agency on Aging the Adm stated, “I guess we have not updated that (home health folder).” The Adm stated “I ordered the patient packets in bulk of 500. I have not ordered any in a while.” When asked about the agency’s policy on providing patients updated community, state, and federal resource contact information the Adm stated, “I really do not know all the policies by heart, but I can find out.” When asked about the potential outcomes for patients that received the incorrect QIO and missing Agency on Aging contact information the Adm stated, “I believe the patient would call us directly for the information.” Review of agency’s policy “Patient/Client Rights and Responsibilities, Rl.5,” revision 05/01/2024, reads in part “The patient/client and representatives (if any), will be informed of the patient’s/client’s rights and responsibilities in a language and manner the individual understands. The Agency will protect and promote the exercise of these rights. Procedure… Be advised of the names, addresses, and telephone numbers of the following federally funded and state funded entities that serve the area where the patient/client resides…Agency on Aging, Quality Improvement Organization.”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care for 5 (Patients 2,3,5,7 and 8) of 12 active patients’ records reviewed. This failure placed patients at risk of not receiving treatments ordered by a physician, which could lead to poor patient health outcomes. Record review of Patient 2 revealed a POC for period 04/23/2025 to 06/21/2025 signed by RN B on 04/23/2025 with nurse visits ordered twice a week for 9 weeks. Records contained wound orders to the right and left leg, heels, and planter feet (bottom of the feet) from patient 2’s physician dated 4/22/2025. RN B documented the use of calcium alginate (wound dressing made from seaweed fibers) during wound care to Patient 2’s left “calf” (lower leg behind the shin bone) during the wound care visits on 4/28/2025 and 4/30/2025. Patient 2’s POC did not contain orders for wound care, an addendum to the POC or a physician order for the use of calcium alginate. Record review of Patient 3 revealed a POC for period 04/22/2025 to 06/20/2025 signed by RN B with nurse visit frequency once a week for 2 weeks. The OASIS start of care dated 04/22/2025 and signed by RN B read in part “Wound 7-Location: Lower midback, Treatment: Wound was cleansed using normal saline (solution of salt and water), then covered gauze, abdominal pad (absorbent pad) and secured with paper tape.” Patient 3’s records did not contain wound orders on the POC. Record review of Patient 5 revealed a POC for period 05/12/2025 to 05/28/2025 and a OASIS start of care visit dated 05/12/2025 signed by PT C with physical therapy visits ordered twice a week for 4 weeks then once a week for 4 weeks. Records contained a skilled nurse evaluation dated 05/13/2025 signed by RN B. The nurse evaluation documentation read in part “Wound 1-Location: Midback, Treatment: Wound was cleansed using normal saline (solution of salt and water), then covered with non-adherent transparent dressing (non-sticking clear covering). Wound 2-Location: Mid-abdomen (belly), Treatment: Wound was cleansed using normal saline then covered with foam dressing.” Records contained a physician order dated 05/13/2025 signed by RN B with nurse visits once a week for 2 weeks. The physician order did not contain wound treatment orders for Wound 1 and Wound 2. Patient 5’s records did not contain an updated POC or addendum to the initial POC. Record review of Patient 7 revealed a POC for period 04/16/2025 to 06/14/2025 signed by RN B with nurse visit frequency twice a week for 5 weeks. Records contained an OASIS start of care visit dated 04/16/2025 and signed by RN B. Documented wound care to the mid-abdomen (belly) read in part “Treatment: cleansed with normal saline (solution of salt and water), wet to dry dressing was applied and covered with gauze and secured with border gauze (non-sticking pad with an adhesive border). Documented wound care to right knee read in part “Treatment: cleansed with normal saline, collagenase (ointment that contains a type of protein to promote wound healing) was applied and covered with gauze then secured with border gauze.” Records contained wound care orders from a wound care center dated 4/28/2025 and 05/02/2025. Patient 7’s records did not contain wound orders on the initial POC or addendum (attachment) updating the POC. Record review of Patient 8 revealed a POC for period 05/08/2025 to 07/06/2025 signed by RN B with nurse visit frequency one week 1 then twice a week for 4 weeks. The OASIS start of care dated 05/08/2025 and signed by RN B read in part “Wound 2- Location right great toe. Treatment: removed the old dressing, then cleansed with normal saline (solution of salt and water), collagenase (ointment that contains a type of protein to promote wound healing) was applied and covered with foam dressing then secured with bordered gauze (non-sticking pad with an adhesive border).” Patient 8’s records did not contain wound orders on the POC. An interview was conducted with RN B on 06/03/2025 at 12:42 pm. The surveyor asked about the process of receiving wound orders during patients’ admissions to the agency. RN B stated the agency nurses notified the doctors that the patients were admitted and needed “weekly updates on the orders.” RN B stated, during the wound care visits patients are asked for the written instructions the wound care doctor gave to the patient. When asked how the orders are added to the patients’ records, RN B stated, “I usually take a picture of the order and send it to my director (DCS) to have it uploaded in the patient’s chart. If I talk to the doctor by phone, I can write a telephone order.” When asked about the agency’s policy on adding orders to the POC, RN B stated “I can do the additional plan of care (addendum)” to add the order. The surveyor shared the findings on Patients 2, 3, 5, 7, and 8 and asked why the agency’s policy was not followed. RN B stated, with Patient 5 she “must of overlooked” adding the wound treatment orders to the order written on 5/13/2025. RN B stated with Patient 2 “I’ll check on that…I know I got the order…I spoke to the doctor about it by phone.” RN B stated on Patients 3, 7 and 8 she added the wound orders to the OASIS start of care. RN B stated “I have to check with my director (DCS)” on the process the order is transferred to the plan of care from the OASIS start of care visit. When asked what the potential patient outcome was for orders not on the POC, RN B stated, “slow wound healing of the patient.” RN B phoned the surveyor on 06/03/2025 at 1:23pm and stated the orders written in the OASIS start of care did not transfer to the POC and there were “problems with the process”. RN B stated on Patient 2 “I didn’t write down the order that was given by the doctor” for the change in wound care treatment to Patient 2’s left calf (lower leg behind the shin bone) on 4/28/2025 and 04/30/2025. An interview was conducted with the Adm and Alt Adm/DCS on 06/03/2025 at 2:23 pm. The surveyor shared the findings of Patients 2,3,5,7, and 8 and asked about the agency’s process on adding orders to the POC. The Alt Adm/DCS stated during the OASIS start of care the nurses enter orders under the “interventions and goals” which transfer over into the plan of care. The Alt Adm/DCS stated after the initial POC was written the nurse adds “supplemental orders.” When asked about the agency’s policy on adding orders to the plan of care, the Alt Adm/DCS stated, the agency nurses “just rewrite orders” and “I have to look at our policy.” When asked about patients’ outcomes for orders not on the POC, the Alt Adm/DCS stated, patients would potentially receive “wrong wound care,” with risk of “deterioration of the wound, infection and hospitalization.” Review of agency’s policy “Plan of Care PC.35,” revision 03/17/2023 reads in part, “The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs. Procedure: Each patient/client must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must include the following: All medications and treatments.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record reviews and interviews the agency failed to conduct a performance improvement project annually to address identified problems with care and to evaluate past performance of the home health agency’s services and operations for 2 (2023 and 2024) of the 3 years of the survey review period. This failure prevented the agency from identifying and correcting problems with the quality of patient care, which put patients at risk of poor health outcomes. Review of the QAPI binder labeled “QAPI 2023” provided by the Administrator on 06/02/2025 contained monthly patient chart reviews for 2022 and a Performance Improvement Project dated 12/30/2022. The binder did not contain evidence of a Performance Improvement Project for 2023 and 2024. A phone interview was conducted with the Alt Adm on 6/02/2025 at 1:09 pm. The surveyor asked about the Performance Improvement Project (PIP) for 2023 and 2024. The Alt Adm stated, “it was not done last year (2024) I did not get around to doing it.” An interview was conducted with the Adm and Alt Adm/DCS on 6/03/2025 at 2:23pm. The surveyor asked about the agency’s policy on their performance improvement process (PIP). The Alt Adm/DCS stated the PIP was reviewed at least twice a year prior to QAPI and a PIP was created when the agency found an area of patient care that needed improvement. When asked why the agency’s policy was not followed, The Adm stated “the same reason QAPI was not done.” The Adm stated the agency “made a lot of cuts and we lost a lot of staff. We can’t afford as many in-house (office) people (staff).” The Adm stated the Alt Adm/DCS was “already overloaded.” When asked about the potential patient outcomes for not completing a PIP the Alt Adm/DCS stated, “problems with care might not be corrected.” The Alt Adm/DCS and Adm did not provide PIP documents for 2023 and 2024. Review of agency’s policy “Quality Assessment Performance Improvement Program, QAPI.5,” revision 01/13/2018 reads in part “The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. Procedure: Performance improvement projects. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations.”

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record reviews and interviews the agency failed to ensure all nursing services are provided under the supervision of a registered nurse in that: The RN’s failed to monitor and evaluate LPN/LVN performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs (as delegated by the RN) for 2 (Patient 9 and 10) of 5 discharged patients records reviewed. This failure prevented the RN’s evaluation of the LVNs competency in delivering safe nursing care which potentially placed patients at risk of poor and unsafe care. Record review of Patient 9 revealed a POC for period 04/11/2025-06/09/2025 signed by PT C on 04/11/2025. The POC contained PT visits one week 1, then 3 times a week for 2 weeks, then 2 times a week for 1 week and nurse to evaluate and treat. Records contained a nurse evaluation visit and physician order dated 04/14/2025 with nurse visit frequency twice a week for 2 weeks, then once a week for 1 week for wound care to left thumb signed by the ADON. Patient 9’s records contained a nurse visit by LVN A on 4/16/2025 and a Discharge Summary dated 04/28/2025 signed by the ADON. Patient 9’s RN visit notes did not contain evidence of a supervisory visit of LVN A. Record review of Patient 10 revealed a POC for period 06/08/2022 to 08/06/2022 signed by RN C with nurse visits ordered twice a week for 3 weeks for wound care to an abdominal (belly) incision (cut made on the body by a sharp instrument during surgery) and PT to evaluate and treat. Records contained nurse visits from LVN B for 6/10, 6/14, 6/17 and 6/21. The Discharge Summary dated 06/24/2022 signed by RN C did not contain evidence of a supervisory visit of LVN B. An interview was conducted on 06/03/2025 at 12:17 pm with former RN C. The surveyor asked about the agency’s policy on LVN supervisory visits. RN C stated, “I don’t quite remember the policies, I don’t know if it’s a 14- day thing.” The surveyor shared the findings of Patient 10 and asked about the missed supervisory visit on LVN B. RN C stated “I don’t remember if I assigned it (LVN supervisory visit) to myself…I don’t remember that nurse (LVN B) and the patient (Patient 10)” When asked about the potential outcome for the patient if the LVN was not supervised, RN C stated, the RNs would not be able to assess the care provided by the LVN. An interview was conducted on 06/02/2025 at 2:31 pm with the ADON. The surveyor asked about the agency’s policy on LVN supervisory visits. The ADON stated “The LVN supervisory visits are usually done during discharge” or during a patient’s recertification visit. The surveyor asked how LVN supervisory visits were done when patients are on service with the agency for less than a month. The ADON stated many of the patients were orthopedic (disease or injury to bones, joints, tendons, muscles, or nerves) patients and were “ready to discharge after two to three weeks” and LVN supervisory visits “should all be done at discharge.” The surveyor shared the findings of Patient 9 and asked why the agency’s policy was not followed. The ADON stated “I do not see the LVN supervisory visit. That might have been because there was only one visit by the LVN…there should have been one (LVN supervisory visit) in there for her (LVN A).” When asked what the potential outcome could have been for the patient, the ADON stated “it can affect communication and coordination regarding patient’s care.” An interview was conducted with the Adm and Alt Adm/DCS on 06/03/2025 at 2:23pm. The surveyor discussed the findings of Patient 9 and 10 and asked about the agency’s policy on LVN supervisory visits. The Alt Adm/DCS stated LVN supervisory visits are done at the “end of care” and when the patient is “recertified” to remain on services. The Alt Adm/DCS stated “with the short turnarounds (patients on service for less than a month) the supervisory visit should be done during the discharge visit.” When asked why the agency’s policy on LVN supervisory visits was not followed, the Alt Adm/DCS stated “that is something we are working on with the nurses.” The Alt Adm/DCS stated, “there is no way to add the supervisory visit with the discharge skilled nurse visit”. The Alt Adm/DCS stated she emailed the electronic medical record software company to combine the supervisory visit with the discharge skilled nurse visit. The Alt Adm/DCS stated the agency can “schedule an additional visit (supervisory visit)” if the changes in the agency’s software cannot be made. Review of agency’s policy “Employee Supervision, HR.60” revision 10/12/2021, reads in part “The Agency will provide timely supervision of the following employees by qualified individuals: A qualified RN will supervise the license professional/vocational nurse (LPN/LVN) at least every 60 days or more frequently as indicated by state practice act or based upon patient/client acuity.