Every finding on record at Trusted Quality Home Health, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey, conducted at this unapproved location: 120 N Victory Blvd, Suite 303, Burbank, CA 91502. Federal Complaint number:101850 Representing the California Department of Public Health: Surveyor ID #22303, Health Facilities Evaluator Nurse Surveyor ID #44186, Health Facilities Evaluator Nurse Surveyor ID #49518, Health Facilities Evaluator Nurse Unduplicated admissions: 1175 Active patients: 750 Sample Size: 17 Home Visits: 7 The following Conditions of Participation not met: 484.55 Comprehensive Assessment of Patients 484.60 Care Planning, Coordination of Services, and Quality of Care 484.100 Compliance with Federal, State, and local laws and regulations related to health and safety of patients 484.110 Clinical Records

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to ensure the agency skilled nurses performed a comprehensive pain re-assessment for one of 17 sampled patients (Patient 15). (Refer to G528) 2. The HHA failed to assess the patient’s continuing need for home care services for eleven of 17 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, and Patient 11). (Refer to G532) The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the agency skilled nurse (SN) performed a comprehensive pain re-assessment for one of 17 sampled patients (Patient 15). This deficient practice placed the patient at a potential risk for ineffective pain management. Findings: A review of Patient 15's Patient Information sheet indicated Patient 15 was admitted to the HHA on 11/27/2023, with a primary diagnosis of spondylosis (a condition in which there is an abnormal wear on the cartilage and bones of the neck). A review of Patient 15’s “Home Health Certification and Plan of Care” for the period 3/26/24 to 05/24/24, indicated SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit. The plan of care also indicated an order for Morphine sulfate (a medication used to treat moderate to sever pain) oral 15 milligrams (mg, a unit of measure), 1 (one) tablet, four times a day as needed for severe pain. A review of the “LVN Skilled Nursing Visit” note, authored by the Licensed Vocational Nurse (LVN 3), dated 5/1/2024 and 5/8/2024, indicated Patient 15 complained of left abdominal area and back pain 7/10 (on a pain scale, zero (0) indicates no pain and score of 10 indicates unbearable pain). There was no documented evidence of a follow-up pain evaluation/reassessment of pain. During a concurrent interview and record review on 5/24/2024 at 11:25 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the nurse should evaluate pain interventions, assess non-pharmacological and pharmacological interventions, and reassess pain level which should be reflected in the nurse's notes. The ADM/DPCS stated that they always give the licensed nurses education that when they give pain medications during their visits, inform DPCS so she can call for reassessment of pain level and they have to report to the physician if pain is severe. A review of the agency's undated policy and procedure titled, "Pain Assessment", indicated each patient will receive at least an initial pain assessment. When pain is identified, a more comprehensive pain assessment will be completed when warranted by patient’s condition…… Pain assessments will be age-appropriate and will be documented to facilitate regular reassessment and follow up by clinicians. Pain assessment will be documented in the clinical record, and information will be communicated to other caregivers.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for home care services for eleven of 17 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, and Patient 11). This deficient practice resulted in the provision of an unnecessary home health services to the patients who did not need skilled nursing services. Findings: h. During a review of Patient 8's Patient Information sheet indicated a start of care date (SOC) of 11/08/2023, with diagnoses which included hypertensive heart disease ((heart problems that occur because of high blood pressure that is present over a long time), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone causing major symptoms such as fatigue, cold sensitivity, and unexplained weight gain). During a review of Patient 8's Home Health Certification and Plan of Care (POC) for the certification period starting from 3/07/2024 to 5/05/2024, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, for assessment of patient with type 2 diabetes management, hypertensive heart disease, and hypothyroidism, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, blood sugar will remain between 70 mg/dl (milligrams per deciliter, a unit of measure) and 180 mg/dl during the episode, blood pressure and patient’s pulse (heart rate) will remain within established parameters during the episode, and will remain free of adverse medication reaction and will be independent with medication management. Discharge planning indicated to discharge to care of physician but did not indicate any conditions when to discharge the patient from home health service. During a telephone interview with the licensed vocational nurse (LVN 1), on 5/24/2024 at 11:21 a.m., LVN 1 stated Patient 8 was awake, alert, oriented x 3 (to person, place, and time), ambulatory using a cane, takes his medications independently, had no wounds, no hospitalization, no falls, and had good family support at home. During a telephone interview on 5/25/2024 at 2:09 p.m. with Patient 8, Patient 8 stated he was independent with ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), his blood pressure and blood sugar was controlled with medications, has no falls, no wounds, ho hospitalization, and goes to his doctors’ appointment regularly. During review of Patient 8's SN Visit notes for the month of March 2024 to April 2024, indicated Patient 8’s blood sugar was ranging from 119 to 150, and patient’s vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate) were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During a concurrent interview and record, on 5/26/2024 at 12:40 p.m., with the agency’s Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated Patient 8 had no recent hospitalization, no falls, no wound care, no rehabilitation services, and should have been discharged. i. During a review of Patient 9's Patient Information sheet indicated a SOC of 11/08/2023, with diagnoses which included hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and muscle weakness. During a review of Patient 9's Home Health Certification and Plan of Care for the certification period starting from 3/07/2024 to 5/05/2024, included an order for the skilled nurse frequency of visits of once a week for 9 weeks, for assessment of patient with insomnia (persistent problems falling and staying asleep) due to medical condition, spondylosis (a condition in which there is abnormal wear on the cartilage and bones of the neck), and hyperlipidemia, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, blood pressure and respiratory rate will remain within established parameters during the episode, skin integrity will remain intact, and patient will remain free of adverse medication reaction and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge to care of physician but did not indicate any conditions when to discharge the patient from home health service. During a telephone interview with the licensed vocational nurse (LVN 1), on 5/24/2024 at 11:21 a.m., LVN 1 stated Patient 9 was awake, alert, oriented x 3, ambulatory using a cane, takes her medications independently, had no wounds, no hospitalization, no falls, and had good family support at home. During a telephone interview on 5/25/2024 at 2:09 p.m. with Patient 9 family member (Patient 8), Patient 8 stated Patient 9 was doing fine, had no falls and no hospitalization, takes her medications daily, and goes to her doctors’ appointment regularly. During review of Patient 9's SN Visit notes for the month of March 2024 to April 2024, indicated Patient 9 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During a concurrent interview and record, on 5/26/2024 at 12:40 p.m., with the agency’s ADM/DPCS, the ADM/DPCS stated Patient 9 had no recent hospitalization, no falls, no wound care, no rehabilitation services, and should have been discharged. j. During a review of Patient 10's Patient Information sheet indicated a SOC of 11/03/2023, with diagnoses which included type 2 diabetes mellitus (a condition that results in too much sugar circulating in the bloodstream) with hyperglycemia (high blood sugar), and unspecified systolic congestive heart failure (occurs when your heart’s left ventricle cannot pump blood efficiently). During a review of Patient 10's Home Health Certification and Plan of Care for the certification period starting from 3/02/2024 to 4/30/2024, included an order for the skilled nurse frequency of visits of once a week for 1 week, twice a week for 2 weeks, and then once a week for 6 weeks for assessment of patient with type 2 diabetes, congestive heart failure, end stage renal disease (when the kidneys are no longer able to function normally), to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. During a telephone interview with the licensed vocational nurse (LVN 1), on 5/24/2024 at 11:21 a.m., LVN 1 stated Patient 10 was awake, alert, oriented x 3, ambulatory, takes his medications independently, had no wounds, no hospitalization, no falls, and had good family support at home. During a telephone interview on 5/25/2024 at 2:16 p.m. with Patient 10’s family member (FM 1), FM 1 stated Patient 10 was doing fine, had no falls and no hospitalization, had no wounds, and drives him to his doctor’s appointment. During review of Patient 10's SN Visit notes for the month of April 2024, indicated Patient 10 had no pain, and his vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During a concurrent interview and record, on 5/26/2024 at 12:40 p.m., with the agency’s ADM/DPCS, the ADM/DPCS stated Patient 10 had no recent hospitalization, no falls, no wound care, no rehabilitation services, home health goals have been met and should have been discharged. k. During a review of Patient 11's Patient Information sheet indicated a SOC of 12/05/2023, with diagnoses which included hemiplegia (paralysis of one side of the body) following unspecified cerebral vascular disease, and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 11's Home Health Certification and Plan of Care for the certification period starting from 2/03/2024 to 4/02/2024, indicated it did not include an order for the skilled nurse frequency of visits. The POC indicated an order for assessment of patient with hemiplegia, and with hypertensive heart disease, to assess patient for diet compliance, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will remain free of adverse medication reaction, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge to care of physician but did not indicate any conditions when to discharge the patient from home health service. During a telephone interview with the licensed vocational nurse (LVN 2), on 5/24/2024 at 12:24 a.m., LVN 2 stated Patient 11 was awake, alert, oriented but forgetful, ambulatory using a walker, takes his medications independently, had no wounds, no hospitalization, no falls, completed his rehabilitation treatment, and had good family support at home. During review of Patient 11's SN Visit notes for the month of March 2024, indicated Patient 11 had no pain, and his vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During a concurrent interview and record, on 5/26/2024 at 12:40 p.m., with the agency’s ADM/DPCS, the ADM/DPCS stated Patient 11 had no recent hospitalization, no falls, no wound care, no rehabilitation services, home health goals have been met and should have been discharged. During a review of the agency’s undated policy and procedure titled, "Discharge Criteria and Process", indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician (or other authorized licensed independent practitioner) and the organization agree that the goals of home care have been attained or are no longer attainable. a. During a review of Patient 1's Patient Information sheet indicated a SOC of 10/17/2023, with diagnoses which included hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation) and osteoarthritis (occurs when flexible tissue at the ends of bones wears down). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period starting from 2/14/2024 to 4/13/2024, included an order for the skilled nurse frequency of visits of once a week for nine weeks, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. On 5/23/2024, at 1 p.m., a home visit was conducted at Patient 1's residence with LVN 2. Patient 1 was observed walking using a walker. At 1:15 p.m., during an interview with FM 2 (family member), she stated she takes Patient 1 to her medical appointments every month, the patient takes her medications independently, had no wounds, no hospitalization, no falls, and had good family support at home. During review of Patient 1's SN Visit notes for dates 2/14/2024 to 4/13/2024, indicated Patient 1 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. b. During a review of Patient 2's Patient Information sheet indicated a SOC of 10/27/2023, with diagnoses which included osteoarthritis (occurs when flexible tissue at the ends of bones wears down) and hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation) During a review of Patient 2's Home Health Certification and Plan of Care for the certification period starting from 2/24/2024 to 4/23/2024, included an order for the skilled nurse frequency of visits of once a week for one week, twice a week for two weeks, once a week for six weeks, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. On 5/23/2024, at 1 p.m., a home visit was conducted at Patient 2's residence with LVN 3. Patient 2 was observed walking on steady gait without the use of assistive device. At 1:20 p.m., during an interview with Patient 2, he stated stated he takes his own medications independently, does regular exercise by walking around the block every morning. During review of Patient 2's SN Visit notes for dates 2/24/2024 to 4/23/2024, indicated Patient 2 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. c. During a review of Patient 3's Patient Information sheet indicated a SOC of 10/28/2023, with diagnosis which included hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 3's Home Health Certification and Plan of Care for the certification period starting from 2/25/2024 to 4/24/2024, included an order for the skilled nurse frequency of visits of once a week for nine weeks, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. On 5/23/2024, at 3:30 p.m., a home visit was conducted at Patient 3's residence with LVN 3. Patient 3 was observed walking on steady gait without the use of assistive device. At 3:40 p.m., during an interview with Patient 3, she was happy for the care provided that a nurse visits her to check her blood pressure readings and medications. During review of Patient 3's SN Visit notes for dates 2/25/2024 to 4/24/2024, indicated Patient 3 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. e. During a review of Patient 4's Patient Information sheet indicated a SOC of 10/23/2023, with diagnosis which included hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 4's Home Health Certification and Plan of Care for the certification period starting from 2/20/2024 to 4/19/2024, included an order for the skilled nurse frequency of visits of once a week for nine weeks, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. On 5/23/2024, at 2:30 p.m., a home visit was conducted at Patient 4's residence with LVN 3. Patient 4 was observed walking on steady gait without the use of assistive device. At 2:50 p.m., during an interview with FM 3 (family member), she stated she takes Patient 4 to his medical appointments every month, the patient takes his medications independently, had no wounds, no hospitalization, no falls, During review of Patient 4's SN Visit notes for dates 2/20/2024 to 4/19/2024, indicated Patient 4 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. f. During a review of Patient 5's Patient Information sheet indicated a SOC of 10/27/2023, with diagnosis which included hypertension (a condition in which the force of the blood against the artery walls is too high). During a review of Patient 5's Home Health Certification and Plan of Care for the certification period starting from 3/2/2024 to 4/30/2024, included an order for the skilled nurse frequency of visits of once a week for nine weeks, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. On 5/23/2024, at 1 p.m., , a home visit was conducted at Patient 5's residence (Patient 2 and 5 were married couple) with LVN 3. Patient 5 was observed walking on steady gait without the use of assistive device. At 1:30 p.m., during an interview with Patient 2, he stated he gives Patient 5's medication regularly on daily basis and walks everyday for her exercise routines. During review of Patient 5's SN Visit notes for dates 3/2/2024 to 4/30/2024, indicated Patient 5 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. g. During a review of Patient 6's Patient Information sheet indicated a SOC of 8/21/2023, with diagnosis which included hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 6's Home Health Certification and Plan of Care for the certification period starting from 2/17/2024 to 4/16/2024, included an order for the skilled nurse frequency of visits of once a week for nine weeks, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. On 5/23/2024, at 2 p.m., , a home visit was conducted at Patient 6's residence with LVN 2. Patient 6 was observed walking on steady gait without the use of assistive device. At 2:30 p.m., during an interview with FM 3, he stated Patient 6 usually goes out and drives her car for errands. During review of Patient 6's SN Visit notes for dates 2/17/2024 to 4/16/2024, indicated Patient 6 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. h. During a review of Patient 7's Patient Information sheet indicated a SOC of 9/1/2023, with diagnosis which included hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 7's Home Health Certification and Plan of Care for the certification period starting from 2/28/2024 to 4/28/2024, included an order for the skilled nurse frequency of visits of once a week for nine weeks, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The goal included patient will have no hospitalizations during the certification period, will be free from falls and injury, respiratory rate will remain within established parameters during the episode, will achieve pain level less than 2, skin integrity will remain intact, patient will remain free of adverse medication reaction, and patient/caregiver will be independent with medication management. Discharge planning indicated to discharge the patient when medical condition was stable, and patient was no longer in need of skilled services. On 5/23/2024, at 3 p.m., , a home visit was conducted at Patient 6's residence with LVN 4. Patient 7 was observed walking on steady gait without the use of assistive device. At 3:30 p.m., during an interview with FM 4, he stated Patient 7walks, able to jump, cook and clean the house. FM 4 laughed when he was told the agency considered Patient 7 as a home bound individual. During review of Patient 6's SN Visit notes for dates 2/28/2024 to 4/28/2024, indicated Patient 7 had no pain, and her vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During a concurrent interview and record, on 5/26/2024 at 1 p.m., with the agency’s ADM/DPCS, the ADM/DPCS stated Patients 1 to 7 had no recent hospitalization, no falls, no wound care, no rehabilitation services, home health goals have been met and should have been discharged.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in Federal healthcare programs) for Care Planning, Coordination of Services, and Quality of Care as follows: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Care planning, coordination, quality of care as follows: 1. The home health agency (HHA) failed ensure Plan of Care (POC) was signed and dated by the physician within 30 days of the start of care for 7 out of 17 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) certified to receive home health services. (Refer to G572). 2. The HHA failed to provide treatment and services as ordered for two of 17 sampled patients (Patients 5 and 8). For Patient 5, the visiting nurse failed to provide IV (intravenous) antibiotic medication as ordered.This deficient practice placed the patient's wound for slow healing and to get infected. For Patient 8, the HHA failed to provide social work services as needed. (Refer to G580). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Care planning, coordination, quality of care to ensure highest quality health care is provided to patients assessed to receive home health services. Based on interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Care Planning, Coordination of Services, and Quality of Care as follows: 1. The HHA failed ensure the Plan of Care (POC) was signed and dated by the physician within 30 days of the start of care for 7 out of 17 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) certified to receive home health services. (Refer to G572) 2. The HHA failed to document the frequency of services to be provided by the skilled nurse (SN) in the patient’s Plan of Care (POC) for three of 17 sampled patients (Patient 11, Patient 12, and Patient 13). (Refer to G574) 3. The HHA failed to provide social worker services as ordered by the physician for one of 17 sampled patients (Patient 8). (Refer to G580) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services. 1. The HHA failed ensure the physician reviewed, signed, and dated the Plan of Care (POC) within 30 days of the start of care for seven of 17 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) certified to receive home health services. (Refer to G572) This deficient practice had the potential for the patients’ outcomes and goals not to be met. 2. The HHA failed ensure to include the frequency of the services to be provided by the skilled nurse (SN) in the patient’s Plan of Care for three of 17 sampled patients (Patient 11, Patient 12, and Patient 13). (Refer to G574) This deficient practice had the potential to affect the care of the patients. 3. The HHA failed to provide treatment and services as ordered by the physician for two of 17 sampled patients (Patient 5 and Patient 8). a. For Patient 5, the visiting nurse failed to provide intravenous (IV, into a vein) antibiotic medication as ordered. This deficient practice had the potential to place Patient 5 at risk for infection and worsening of the patient's wound. (Refer to G580). b. For Patient 8, the HHA failed to provide social work services as ordered. This deficient practice had the potential for Patient 8’s needs not to be met. (Refer to G580). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) failed ensure the physicians (in general) reviewed, signed, and dated the Plan of Care (POC) within 30 days of the start of care for seven of 17 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) certified to receive home health services. This deficient practice had the potential for the patients’ outcomes and goals not to be met. Findings: a. During a review of Patient 8's Patient Information sheet indicated a start of care date (SOC) of 11/08/2023, with diagnoses which included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels), and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone causing major symptoms such as fatigue, cold sensitivity, and unexplained weight gain). During a review of Patient 8's Home Health Certification and Plan of Care (POC) for the certification period starting from 3/07/2024 to 5/5/2024, the POC included an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks, for assessment of patient with type 2 diabetes management, hypertensive heart disease, and hypothyroidism (low thyroid). The POC indicated to instruct the patient on nonpharmacologic (therapy that does not involve medication) pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs. The POC indicated to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver was able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver could verbalize an understanding of the indication for each medication. The POC indicated Patient 8’s physician did not review, sign, or date Patient 8’s POC. b. During a review of Patient 9's Patient Information sheet indicated a SOC of 11/08/2023, with diagnoses which included hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and muscle weakness. During a review of Patient 9's Home Health Certification and POC for the certification period starting from 3/07/2024 to 5/05/2024, the Home Health Certification and POC indicated an order for the skilled nurse frequency of visits of once a week for nine weeks, for assessment of patient with insomnia (persistent problems falling and staying asleep) due to medical condition, spondylosis (a condition in which there is abnormal wear on the cartilage and bones of the neck), and hyperlipidemia. The POC indicated to instruct the patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver was able to identify the correct dose, route, and frequency of each medication. The POC indicated to assess if the patient/caregiver could verbalize an understanding of the indication for each medication. The POC indicated Patient 9’s physician did not review, sign, or date Patient 9’s POC. c. During a review of Patient 10's Patient Information sheet indicated a SOC of 11/03/2023, with diagnoses which included type 2 diabetes mellitus with hyperglycemia (high blood sugar), and unspecified systolic congestive heart failure (occurs when your heart’s left ventricle cannot pump blood efficiently). During a review of Patient 10's Home Health Certification and POC for the certification period starting from 3/02/2024 to 4/30/2024, the Home Health Certification and POC included an order for the skilled nurse frequency of visits of once a week for one week, twice a week for two weeks, and then once a week for six weeks for assessment of patient with type 2 diabetes, congestive heart failure, end stage renal disease (when the kidneys are no longer able to function normally). The POC indicated to instruct the patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver was able to identify the correct dose, route, and frequency of each medication. The POC indicated to assess if the patient/caregiver could verbalize an understanding of the indication for each medication. The POC indicated Patient 10’s physician did not review, sign, or date Patient 10’s POC d. During a review of Patient 11's Patient Information sheet indicated a SOC of 12/05/2023, with diagnoses which included hemiplegia (paralysis of one side of the body) following unspecified cerebral vascular disease, and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 11's Home Health Certification and POC for the certification period starting from 2/03/2024 to 4/02/2024, and from 4/03/2024 to 6/01/2024, the Home Health Certification and POC indicated there was no order for the skilled nurse frequency of visits. The POC indicated an order for assessment of the patient with hemiplegia, and with hypertensive heart disease. The POC indicated to assess the patient for diet compliance, to determine if the patient/caregiver was able to identify the correct dose, route, and frequency of each medication. The POC indicated to assess if the patient/caregiver could verbalize an understanding of the indication for each medication. The POC indicated Patient 11’s physician did not review, sign, or date Patient 11’s POC e. During a review of Patient 12's Patient Information sheet indicated a SOC of 1/05/2024, with diagnoses which included atherosclerosis of aorta (the gradual buildup of plaque [fat and calcium deposit] in your aorta [main and largest artery in the human body]), and hypertensive heart disease without heart failure. During a review of Patient 12's Home Health Certification and POC for the certification period starting from 3/05/2024 to 5/03/2024, the Home Health Certification and POC indicated there was no order for the skilled nurse frequency of visits. The POC indicated an order for assessment of the patient with hypertensive heart disease, to determine if the patient/caregiver was able to identify the correct dose, route, and frequency of each medication. The POC indicated to assess if the patient/caregiver could verbalize an understanding of the indication for each medication. The POC indicated Patient 12’s physician did not review, sign, or date Patient 12’s POC f. During a review of Patient 13's Patient Information sheet indicated a SOC of 1/30/2024, with diagnoses which included type 2 diabetes mellitus with hyperglycemia, and hypertensive heart disease with heart failure. During a review of Patient 13's Home Health Certification and POC for the certification period starting from 3/30/2024 to 5/28/2024, the Home Health Certification and POC indicated there was no order for the skilled nurse frequency of visits. The POC indicated an order for assessment of patient with type 2 diabetes and hypertensive heart disease, to determine if the patient/caregiver was able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. The POC indicated Patient 13’s physician did not review, sign, or date Patient 13’s POC g. During a review of Patient 14's Patient Information sheet indicated a SOC of 2/02/2024, with diagnoses which included hypertensive heart disease without heart failure and type 2 diabetes mellitus with other specified complication. During a review of Patient 14's Home Health Certification and POC for the certification period starting from 4/2/2024 to 5/31/2024, indicated there was no order for the skilled nurse frequency of visits. The POC indicated an order for assessment of patient with type 2 diabetes and hypertensive heart disease, to assess pain level and effectiveness of pain medications and current pain management therapy, and to instruct patient/caregiver on medication regimen dose, indication, side effects and interactions. The POC indicated to determine if the patient/caregiver was able to identify the correct dose, route, and frequency of each medication. The POC indicated to assess if the patient/caregiver could verbalize an understanding of the indication for each medication. The POC indicated Patient 14’s physician did not review, sign, or date Patient 14’s POC During a concurrent interview and record review of Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14’ POC on 5/26/2024 at 12:40 p.m., with the agency’s Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14’s physician did not evaluate, sign, or dated the Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14’s POC. The ADM/DPCS stated the patients’ physician needed to review, sign, and date the patients' POCs within 30 days from the POC to meet the federal regulations. During a review of the agency’s undated policy and procedure titled “Plan of Care”, indicated a physician (or other authorized licensed independent practitioner) will direct the care of every home health care patient admitted for service. The attending physician (or other authorized licensed independent practitioner) will participate in the care planning process by initiating, reviewing, and revising therapeutic and diagnostic orders. The attending physician (or other authorized licensed independent practitioner) will sign the plan of care.

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 home health agency (HHA) failed to ensure to include the frequency of the services to be provided by the skilled nurse (SN) in the patient’s Plan of Care (POC) for three of 17 sampled patients (Patient 11, Patient 12, and Patient 13). This deficient practice had the potential to affect the care of the patients. Findings: a. During a review of Patient 11's Patient Information sheet indicated a start of care date of 12/05/2023, with diagnoses which included hemiplegia (paralysis of one side of the body) following unspecified cerebral vascular disease, and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition when your heart doe not pump enough blood for your body's needs). During a review of Patient 11's Home Health Certification and Plan of Care for the certification period starting from 2/03/2024 to 4/02/2024, and from 4/03/2024 to 6/01/2024, indicated there was no order for the skilled nurse frequency of visits. b. During a review of Patient 12's Patient Information sheet indicated a SOC of 1/5/2024, with diagnoses which included atherosclerosis of aorta (the gradual buildup of plaque [fat and calcium deposit] in your aorta [main and largest artery in the human body]), and hypertensive heart disease without heart failure. During a review of Patient 12's Home Health Certification and Plan of Care for the certification period starting from 3/5/2024 to 5/3/2024, indicated it did not include an order for the skilled nurse frequency of visits. c. During a review of Patient 13's Patient Information sheet indicated a SOC of 1/30/2024, with diagnoses which included type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar), and hypertensive heart disease with heart failure. During a review of Patient 13's Home Health Certification and Plan of Care for the certification period starting from 3/30/2024 to 5/28/2024, indicated there was no order for the skilled nurse frequency of visits. During a concurrent interview and record review of Patient 11, Patient 12, and Patient 13's medical records, on 5/26/2024 at 12:40 p.m., with the agency’s Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS was not able to provide the documented evidence of the frequency of visits of the agency SN was included in the POC for Patient 11, Patient 12, and Patient 13. The ADM/DPCS stated the frequency of SN visits should have been included in the POC. During a review of the agency’s undated policy and procedure titled “Plan of Care”, indicated a physician (or other authorized licensed independent practitioner) will direct the care of every home health care patient admitted for service. Physician, dentist, podiatrist, or any other licensed practitioner within his or her scope of practice orders will be individualized, based on patient’s needs, and include patient diagnoses, and treatment and/or procedures needed, including type, frequency, duration, and goals.

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 home health agency (HHA) failed to provide treatment and services as ordered for two of 17 sampled patients (Patients 5 and 8). For Patient 5, the HHA failed to provide intravenous (IV, into a vein) antibiotic medication as ordered. This deficient practice had the potential to place Patient 5 at risk for infection and worsening of the patient's wound. For Patient 8, the HHA failed to provide social work services as ordered. This deficient practice had the potential for Patient 8’s needs not to be met. Findings: During a review of Patient 8's Patient Information sheet indicated a start of care date (SOC) of 11/08/2023, with diagnoses which included hypertensive heart disease ((heart problems that occur because of high blood pressure that is present over a long time), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone causing major symptoms such as fatigue, cold sensitivity, and unexplained weight gain). During a review of Patient 8's Home Health Certification and Plan of Care (POC) for the certification period starting from 3/07/2024 to 5/05/2024, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, for assessment of patient with type 2 diabetes management, hypertensive heart disease, and hypothyroidism, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. During a review of a physician order, dated 3/13/2024, indicated an order for the MSW (Medical Social Worker) to visit Patient 8 to help with community resources and IHHS program (or In-Home Supportive Services program, it provides in-home assistance to eligible aged, blind, and disabled individuals). During a concurrent interview and record review, on 5/26/2024 at 12:40 p.m., with the agency’s Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS was unable to provide documented evidence Patient 8 was visited by the agency’s MSW. ADM/DPCS stated the HHA should have carried out the physician order and notified MSW to visit and assess the patient for his psychosocial needs. During a review of the agency’s undated policy and procedure titled “Plan of Care”, indicated a physician (or other authorized licensed independent practitioner) will direct the care of every home health care patient admitted for service. The attending physician (or other authorized licensed independent practitioner) will certify that medical, skilled, rehabilitative, and social services provided by the organization are medically necessary and meets the requirements to be covered by Medicare. a. During a review of Patient 5's Patient Information sheet indicated a SOC of 11/3/2023, with diagnosis which included Stage pressure ulcer at left buttock. (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising). During a review of Patient 5's Home Health Certification and Plan of Care for the certification period starting from 11/3/2023 to 1/1/2023, included an order for the skilled nurse frequency of visits of daily for six days, once a week for four weeks, once a week for six weeks, to do assessment of patient's Stage two pressure ulcer at left buttocks. One of skilled nurse intervention was to provide wound treatment to left buttocks as follows: to administer Ertapenem Sodium Injection one gram each to infuse IV (intravenously) daily over 30 minutes for six days for infection. A review of Patient 5's Skilled Nursing Visit notes dated 11/3/23 to 11/8/23, indicated no documented evidence the visiting nurse administered the IV Ertapenem medication as ordered. On 5/26/24, at 2 p.m. during an interview with the DPCS, she stated she could not find any documentation that the visiting nurse administered the IV Ertapenem medication to Patient 5 as ordered.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure to notify one of 17 sampled patients (Patient 15) physician was notified of Patient 15's right toe unspecified wound on 12/22/2023. This deficient practice had the potential Patient 15 not to receive care and treatment. Findings: During a review of Patient 15's Patient Information sheet indicated patient was admitted on 11/27/2023, with a primary diagnosis of spondylosis (a condition in which there is an abnormal wear on the cartilage and bones of the neck). During a review of Patient 15’s Home Health Certification and Plan of Care, period 11/27/23 to 1/25/24, the Home Health Certification and Plan of Care indicated an order of SN frequency of visits to once a week for nine weeks to assess skin breakdown every visit. During a review of Skilled Nursing Visit Wound Care Worksheet, dated 12/22/2023, indicated skilled nurse (Licensed Vocational Nurse, LVN 3) assessed a new unspecified wound on Patient 15’s right toe. The Skilled Nursing Visit Wound Care Worksheet indicated LVN 3 cleansed the right fifth toe with soap and water. During a concurrent interview and record review of Patient 15's medical record, on 5/24/2024, at 11:25 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the HHA did not notify Patient 15’s physician of Patient 15's open wound to the right toe. The ADM/DPCS stated there was no documented evidence Patient 15’s physician was notified of new open wound on the right toe. During a review of the agency's undated policy titled, Ongoing Assessments/Change of Condition, indicated the HHA would notify the physician and would verify any changes…treatment/interventions that require physician approval.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Compliance with Federal, State, Local Law as follows: The HHA failed to operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. This deficient practice had the potential for the patients not to received care and services and the agency's non-compliance with licensing requirements for all 750 active patients. (Refer to G-850). The HHA failed to ensure that their State license were valid and not expired in order to continue to furnish services to their patients. This deficient practice had the potential for 750 patients not to received services and required with licensing requirements. (refer to G-860). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Compliance with Federal, State, Local Law to ensure highest quality health care is provided to patients assessed to receive home health services.

Disclosure of ownership and management info. CFR(s): 484.100(a) Standard: Disclosure of ownership and management information. The HHA must comply with the requirements of part 420 subpart C, of this chapter. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients for 750 active patients. This deficient practice had the potential for the patients not to received care and services and the agency's non-compliance with licensing requirements for all 750 active patients. A review of the HHA's letter from CDPH (California Department of Public Health) dated 2/22/2024, indicated the agency's application packet for a change of geographical service area to expand to San Diego and Imperial counties were received, confirmed that the documents were complete, approved by CAB (centralized applications branch) and will be forwarded to Los Angeles District Office for final approval. A review of the HHA's Active Patient Roster dated 5/21/2024, indicated there were 750 active patients residing in Imperial County under the agency's patient care services. On 5/22/2024, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated the HHA location is in LA County but all the agency's staff including Registered Nurse (RN), Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) lives at Imperial County and they all work remotely. The DPCS stated that all 750 active patients resides in Imperial County. The DPCS stated that the agency was approved by the Department to extend their geographical area of service all the way to Imperial County. A review of the State Licensing Electronic Management System (ELMS) on 5/23/2024, indicated there were no approval for a change of geographic service to extend service to Imperial County area. A review of the HHA's policy "Scope of Services", indicated the agency will operate an office that will provide a safe and adequate location related to space, facilities and administrative services. A review of the Title 22 CCR Section 74607 (a), indicated (a) "Parent home health agency" means the primary home health agency which establishes, maintains and assures administrative and supervisory control of branch offices. The service area of a parent home health agency may not extend beyond four hours surface travel time from the agency unless the agency serves a rural, scarcely populated area pursuant to Section 74663.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that their State license were valid and not expired to continue to furnish care and services to their patients. The HHA active patients were 750. This deficient practice had the potential for the HHA's patients not to received care and services and applicable with licensing requirements. Findings: During a review of the HHA's State license indicated their license expired on 4/26/2024. On 5/21/2024, at 2:00 p.m., a complaint validation survey was conducted at this agency regarding a complaint allegation wherein the HHA was providing service in a geographical area that the agency was not authorized to provide service. During a review of the HHA's Active Patient Roster dated 5/22/2024, indicated there were 750 active patients under the agency's patient care services. During an interview on 5/22/2024 at 2:15 p.m., with the agency’s Office Manager (OM 1), OM1 stated he was going to check with the agency’s consultant regarding the status of the agency’s State License renewal. On 5/26/2024 at 11:40 a.m., OM 1 presented a copy of the check for the renewal payment. A review of the HHA's copy of check payment for the renewal of license indicated it was dated on 5/17/2024. During a review of the State Licensing Electronic Management System (ELMS) indicated the HHA 's State license had expired, and the agency have not submitted a renewal application to CAB (Centralized Applications Branch, is primarily responsible for processing licensing and certification applications for health care facilities and providers).

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation for Clinical Records was met as follows: - the Home Health Agency failed to ensure patients' clinical records were completed, signed, and dated for 7 out of 17 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to G1024) The cumulative effect of this systemic practice resulted in the failure of the HHA to ensure the provision of a quality health care in a safe environment.

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 Home Health Agency (HHA) failed to ensure patients' clinical records were completed, signed, and dated for seven out of 17 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) The deficient practice resulted in incomplete clinical records. Findings: a. During a review of Patient 8's Patient Information sheet indicated a start of care date (SOC) of 11/08/2023, with diagnoses which included hypertensive heart disease ((heart problems that occur because of high blood pressure that is present over a long time), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone causing major symptoms such as fatigue, cold sensitivity, and unexplained weight gain). During a review of Patient 8's Home Health Certification and Plan of Care (POC) for the certification period starting from 3/07/2024 to 5/05/2024, included an order for the skilled nurse (SN) frequency of visits of once a week for 9 weeks, for assessment of patient with type 2 diabetes management, hypertensive heart disease, and hypothyroidism, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. Further review of the POC indicated that the area for the physician signature and date signed was blank. b. During a review of Patient 9's Patient Information sheet indicated a SOC of 11/08/2023, with diagnoses which included hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and muscle weakness. During a review of Patient 9's Home Health Certification and Plan of Care for the certification period starting from 3/07/2024 to 5/05/2024, included an order for the skilled nurse frequency of visits of once a week for 9 weeks, for assessment of patient with insomnia (persistent problems falling and staying asleep) due to medical condition, spondylosis (a condition in which there is abnormal wear on the cartilage and bones of the neck), and hyperlipidemia, to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. Further review of the POC indicated that the area for the physician signature and date signed was blank. c. During a review of Patient 10's Patient Information sheet indicated a SOC of 11/03/2023, with diagnoses which included type 2 diabetes mellitus with hyperglycemia (high blood sugar), and unspecified systolic congestive heart failure (occurs when your heart’s left ventricle cannot pump blood efficiently). During a review of Patient 10's Home Health Certification and Plan of Care for the certification period starting from 3/02/2024 to 4/30/2024, included an order for the skilled nurse frequency of visits of once a week for 1 week, twice a week for 2 weeks, and then once a week for 6 weeks for assessment of patient with type 2 diabetes, congestive heart failure, end stage renal disease (when the kidneys are no longer able to function normally), to instruct patient on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and/or hot/cold packs, to assess for patient adherence to appropriate activity levels, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. Further review of the POC indicated that the area for the physician signature and date signed was blank. d. During a review of Patient 11's Patient Information sheet indicated a SOC of 12/05/2023, with diagnoses which included hemiplegia (paralysis of one side of the body) following unspecified cerebral vascular disease, and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 11's Home Health Certification and Plan of Care for the certification period starting from 2/03/2024 to 4/02/2024, and from 4/03/2024 to 6/01/2024, indicated it did not include an order for the skilled nurse frequency of visits. The POC indicated an order for assessment of patient with hemiplegia, and with hypertensive heart disease, to assess patient for diet compliance, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. Further review of the POC indicated that the area for the physician signature and date signed was blank. e. During a review of Patient 12's Patient Information sheet indicated a SOC of 1/05/2024, with diagnoses which included atherosclerosis of aorta , and hypertensive heart disease without heart failure. During a review of Patient 12's Home Health Certification and Plan of Care for the certification period starting from 3/05/2024 to 5/03/2024, indicated it did not include an order for the skilled nurse frequency of visits. The POC indicated an order for assessment of patient with hypertensive heart disease, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. Further review of the POC indicated that the area for the physician signature and date signed was blank. f. During a review of Patient 13's Patient Information sheet indicated a SOC of 1/30/2024, with diagnoses which included type 2 diabetes mellitus with hyperglycemia, and hypertensive heart disease with heart failure. During a review of Patient 13's Home Health Certification and Plan of Care for the certification period starting from 3/30/2024 to 5/28/2024, indicated it did not include an order for the skilled nurse frequency of visits. The POC indicated an order for assessment of patient with type 2 diabetes and hypertensive heart disease, to determine if the patient/caregiver is able to identify the correct dose, route, and frequency of each medication, and to assess if the patient/caregiver can verbalize an understanding of the indication for each medication. Further review of the POC indicated that the area for the physician signature and date signed was blank. g. During a review of Patient 14's Patient Information sheet indicated a SOC of 2/02/2024, with diagnoses which included hypertensive heart disease without heart failure and type 2 diabetes mellitus with other specified complication. During a review of Patient 14's Home Health Certification and Plan of Care for the certification period starting from 4/02/2024 to 5/31/2024, indicated it did not include an order for the skilled nurse frequency of visits. The POC indicated an order for assessment of patient with type 2 diabetes and hypertensive heart disease, to assess pain level and effectiveness of pain medications and current pain management therapy, and to instruct patient/caregiver on medication regimen dose, indication, side effects and interactions. Further review of the POC indicated that the area for the physician signature and date signed was blank. During a concurrent interview and record review, on 5/26/2024 at 12:40 p.m., with the agency’s Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that plan of care should be signed by a physician within 30 days from the SOC. The ADM/DPCS further stated the plan of care and other patient records should all be signed and dated. During a review of the agency’s undated policy and procedure titled, “Entries into the Clinical Record”, indicated home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents).