Every finding on record at United Integrity Home Health Inc

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Recertification surveys. The survey team entered the home health agency on 1/22/25 at 1130 hours. The home health agency identified the census as 53. The survey sample size was 8. GLOSSARY AND DEFINITIONS: DPCS: Director of Patient Care Services HHA: Home Health Agency

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included an updated facility-based and community-based risk assessment utilizing an all-hazards approach, creating the potential risk of not providing the necessary care and services to the patients during the emergency events. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/28/25. * However, there was no documented evidence of the HHA’s updated facility-based and community-based risk assessment using an all-hazards approach. On 1/29/25 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan analyze the response to the HHA's emergency drills. This failure created the risk of not identifying the gaps in the HHA's emergency program in responding to various types of emergencies. Findings: Review of the agency's 2024 emergency preparedness program documents was conducted on 1/28/25. The Staff Meetings for Tsunami Ready Preparedness dated 3/15/23, and Earthquake Drill dated 10/19/23, showed the list of staff who attended the meetings. On 1/29/25 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She stated on 3/15/23 and 10/19/23, an individual facility based functional exercise and an emergency drill were conducted, respectively * However, there was no documented evidence the HHA had analyzed its response to the emergency drills on 3/15/23 and 10/29/23. On 1/29/25 at 1000 hours, the Administrator/DPCS was informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent Recertification and Emergency Preparedness Surveys. The survey team entered the home health agency on 1/22/25 at 1130 hours. The home health agency identified the census as 53. The survey sample size was 8. GLOSSARY AND DEFINITIONS: ADL: activities of daily living BP: Blood Pressure BID: two times a day CHHA: Certified Home Health Aide D5NS: dextrose 5% in normal saline 0.9% (a combination of a sugar and a salt used as a source of water, electrolytes, and calories) D5 1/2 NS: dextrose 5% in normal saline 0.45% (a combination of a sugar and a salt used as a source of water, electrolytes, and calories) Dementia: general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life dl: deciliter(s) DME: Durable Medical Equipment DPCS: Director of Patient Care Services GERD: gastroesophageal reflux disease (a common condition in which the stomach contents move up into the esophagus) Hepatitis B: an infection of the liver caused by the hepatitis B virus HHA: Home Health Agency Hypothyroidism: a condition in which the thyroid gland does not make enough thyroid hormone HS: at bedtime IADL: Instrumental activities of daily living (skis that enable people to live independently) LVN: Licensed Vocational Nurse mcg: microgram(s) MD: Medical Doctor mg: milligram(s) ml: milliliter(s) mmHg: milliliter(s) of mercury NS: normal saline OASIS: Outcome and Assessment Information Set Oxygen saturation level: the percentage of oxygen in a person's blood P&P: Policy and Procedure PO: By mouth POC: Plan of Care PRN: As Needed PT: Physical Therapy/Therapist PTA: Physical Therapy Assistant Q: Every QD: Daily RCFE: Resident Care Facility for Elderly RN: Registered Nurse Systolic Blood Pressure: the pressure in the arteries when the heart beats, the top number in a blood pressure reading SN: Skilled Nursing/Nurse SOC: Start of Care Stage 1 Pressure Injury: non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin TB: tuberculosis (a bacterial infection that primarily affects the lungs) Tetanus: a serious disease of the nervous system caused by a toxin-producing bacterium W: Week

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the initial assessment visits were conducted within 48 hours after referral for one of eight sampled patients (Patient 6). This failure had the potential for not providing the necessary care and services timely to this patient. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient's OASIS E-Start Of Care was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. However, further review of the clinical record showed no documented evidence of the reason why the SOC was 3/2/23, instead of the 48 hours after the referral date of 2/24/23. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the clinical record and acknowledged the finding.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for four of eight sampled patients (Patients 2, 3, 6, and 8). This failure had the potential for not identifying and addressing the care needs timely for these patients. #. Review of Patient 2's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The OASIS-E Start of Care dated 12/3/24, showed the patient information for tetanus, TB, and hepatitis B immunization was not completed. In addition, the information about TB exposure was not completed. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Start of Care dated 9/1/24, showed the patient information for patient’s weight, orientation to time, place, and situation were not completed. In addition, the patient’s TB, and hepatitis B immunization; and TB exposure were not completed. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The OASIS - E Start of Care dated 6/28/24, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the patient Most Recent Immunizations. The assessment showed the patient had immunization for pneumonia and flu. However, the RN did not complete the initial comprehensive assessment timely as the immunization on the sections for Tetanus, TB, TB Exposure and Hepatitis B immunization was left blank. On1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledge the findings. 2. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The OASIS- E Start of Care dated 3/2/23, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the digestive body system. However, the section for digestive body system was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the clinical record and acknowledged the finding. Findings: 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The OASIS - E Start of Care dated 6/28/24, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the patient's most recent immunizations which were pneumonia and flu. However, the RN did not complete the assessment for other immunization as the immunization sections for Tetanus, TB, TB Exposure and Hepatitis B immunization were left blank. On1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledge the findings. 2. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The OASIS- E Start of Care dated 3/2/23, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the digestive body system. However, the section for digestive body system was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the clinical record and acknowledged the findings. 3. Review of Patient 2's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The OASIS-E Start of Care dated 12/3/24, showed the patient's tetanus, TB, and hepatitis B immunization were not completed. In addition, the information about TB exposure was not completed. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 4. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Start of Care dated 9/1/24, showed the patient’s weight, orientation to time, place, and situation were not completed. In addition, the patient’s TB, and hepatitis B immunization; and TB exposure were not completed. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included all of the patient's current medications to identify any potential adverse effects and drug reactions for three of eight sampled patients (Patients 1, 2 and 3 ). This failure posed the risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. #. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Medication Profile for the certification period from 12/9/24 to 2/6/25, showed the patient's medications included omeprazole (used to treat GERD) 40 mg one capsule daily. A joint home visit with CHHA 2 was conducted on 1/23/25 at 1016 hours, to Patient 1's home. Review of the patient's medications with the RCFE Administrator and CHHA 2. The RCFE Administrator stated omeprazole 40 mg one capsule daily was discontinued a month ago. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 2's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The Medication Profile for the certification period from 12/3/24 to 1/31/25, showed the patient's medications included Ativan (antianxiety) 0.5 mg one tablet at HS and levothyroxine sodium (hormone) 25 mcg one tablet daily. A joint home visit with the PTA was conducted on 1/23/25 at 1300 hours, to Patient 2's home. Review of the patient's medications with the patient was performed. The patient stated Ativan was taken when needed instead of routinely at HS and levothyroxine sodium was taken every other day instead of daily. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. The Administrator/DPCS stated the RN did not administer D5 1/2 NS. They were informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The Medication Profile for the certification period from 12/25/24 to 2/22/25, showed the patient's medications included wound treatment for right foot - forefoot. Cleanse the wound with normal saline prior to applying a clean dressing. Do not scrub or use excessive force at time of dressing change. Apply mupirocin 2% ointment to wound daily then apply thin film of barrier ointment to protect skin surrounding the wound. Do not get ointment in the wound bed. Apply primary dressing to wound PRISMA then HFBR and secure with rolled gauze and tape change 3 times a week. Bactrim DS Oral (antibiotic) 800 -160 mg one tablet PO BID for 14 days, pantoprazole sodium oral (anti spasmodic) 40 mg one tablet PO before breakfast, metformin HCL oral (anti diabetic) 500 mg PO BID, Tresiba FlexTouch Subcutaneous (insulin)100 mg unit/ml inject 12 units subcutaneously every night at bedtime, Omeprazole Oral (antispasmodic) 40 mg one capsule PO QD, Ramipril Oral (antihypertensive) 5 mg one capsule PO QD, Rosuvastatin calcium oral (antihyperlipidemic) 20 mg PO QD, clopidogrel bisulfate oral (hematological) 75 mg PO QD, ferrous sulfate oral (hematopoietic) 325 mg (65 Fe) Mg one tablet PO BID, xarelto oral (anticoagulant) 2.5 mg PO BID, gabapentin oral (anticonvulsant) 300 mg three capsules BID and metoprolol succinate ER (beta blockers) 25 mg one table PO QD. A wound care orders dated 1/21/25 showed an order for wound care: Cleanse the wound with normal saline prior to applying a clean dressing. Do not scrub or use excessive force at time of dressing change. Apply thin film of barrier ointment to protect skin surrounding the wound. Do not get ointment in the wound bed. Apply topical antibiotic/antimicrobial in a thin film to wound bed then cover with clean dressing- mupirocin. Apply primary dressings to wound - HFBR and secure with rolled gauze and tape - change three times a week. A joint home visit with LVN 1 was conducted on 1/23/25 at 1000 hours, to Patient 3's home. Review of the patient's medications showed the instructions for Tresiba FlexTouch (insulin degludec) injection 100 units/ml was to administer 28 units under skin at bedtime instead of 12 units as written on the medication profile. On 1/23/25 at 1127 hours, an interview and concurrent clinical record review was conducted with the LVN 1. LVN 1 was informed and acknowledged the findings. On 1/29/25 at 0940 hours, the finding was shared with the LVN Case Manager. The LVN Case Manager acknowledged the finding.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for four of eight sampled patients (Patients 3, 4, 6, and 8 ). This failure had the potential for not addressing the care needs for these patients. #. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. a. The OASIS-E Recertification dated 10/27/24, showed the patient information for patient’s TB, and hepatitis B immunization; and TB exposure were not completed. b. The OASIS E-Recertification dated 12/26/24, showed the patient information for patient’s height, weight, orientation to time, place, and situation were not completed. In addition, the patient’s TB, and hepatitis B immunization; and TB exposure were not completed. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 8/2/24. The patient was certified for home health services during the certification periods from 10/2/24 to 11/29/24 and 11/30/24 to 1/28/25. The OASIS-E Recertification dated 9/27 and 11/29/24, showed no documented evidence the patient’s height and weight were completed. On 1/29/25 at 0905 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. a. Review of the OASIS Recertification dated 12/20/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment included a section for height and weight. However, the section for height and weight were left blank. In addition, on the section of Most Recent Immunization showed the patient had received immunization for Pneumonia and Flu. However, for the section on Tetanus, TB, TB Exposure and Hepatitis B immunization was left blank. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. b. Review of the OASIS Recertification dated 10/25/24, showed the RN had performed a comprehensive assessment. The assessment included a section for the Most Recent Immunization. The immunization showed the patient had received Pneumonia and Flu. However, for the section on Tetanus, TB, TB Exposure and Hepatitis B immunization was left blank. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The OASIS Recertification dated 10/27/23, showed the RN had performed the comprehensive assessment. The comprehensive assessment included the section for height and weight. However, the section for height and weight were left blank. In addition, on the section of the body system assessment included the digestive system. However, the section for digestive body system was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the finding.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the update comprehensive assessment was completed within 48 hours of the patient's return to home from the acute care hospital for one of eight sampled patients (Patient 1). This failure created the risk of not providing the necessary care and services timely to meet the care needs for this patient. Findings: Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient's immunization for tetanus, TB, and hepatitis B immunization were not completed. In addition, the information about TB exposure and the assessment of the digestive system were not completed. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the POCs included specific information related to medications and assessment of blood sugar for two of eight sampled patients (Patients 3 and 6). This failure had the potential for not addressing the care needs for these patients. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The patient's primary diagnoses was Type 2 Diabetes Mellitus with foot ulcer. a. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1 (one visit a week for one week) and 2W8. The POC showed SN to assess blood sugar level via finger stick every visit prior to insulin administration and notify the physician if fasting blood sugar level greater than 300 mg/dl or less than 60 mg/dl and random blood sugar level greater than 400 mg/dl or less than 60 mg/dl. However, the POC failed to include specific instructions regarding the type of blood sugar testing needed to be performed during SN visits. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was asked if the SN needed to check both fasting and random blood sugar levels. The LVN Case Manager replied no, they did not have to check both, only the random blood sugar level. The LVN Case Manager was also asked if the instructions related to blood sugar check was specific in the POC. The LVN Case Manager replied no, it should be specific for random blood sugar check. The LVN Case Manager was further asked if the SN administered the patient's insulin. The LVN Case Manager replied no, the patient's insulin was to be given at night time. The LVN Case Manager was informed and acknowledged the findings. b. The POC, for the certification period from 10/26/24 to 12/24/24, cited SN visits 2W9. The POC cited SN to assess blood sugar level via finger stick every visit prior to insulin administration and notify the physician if fasting blood sugar greater than 300 mg/dl or less than 60 mg/dl and random blood sugar level greater than 400 mg/dl or less than 60 mg/dl. However, the POC failed to include specific instructions regarding the type of blood sugar testing needed to be performed during SN visits. In addition, review of the SN notes dated 11/29, 12/2 and 12/6/24, showed the blood sugar level was checked by the patient. However, the POC failed to include specific instruction for the patient to check the blood sugar levels during non SN visit days. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was asked if they needed to have a specific instructions in the POC for the patient to check the blood sugar levels on non SN days. The LVN Case Manager replied yes, it should have been written on the POC. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The POCs, for the certification periods from rom 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23, showed the patient's medications included the following PRN medications. - acetaminophen (pain medication) 500 mg one tablet PO four times QD PRN for pain, - diclofenac sodium external (nonsteroidal anti-inflammatory medication) 1% 100 mg apply to affected area PRN for pain, and - Restasis ophthalmic (for dry eye) 0.05% 1 ml one drop on each eye PRN. However, the POCs did not include specific information as to when to administer these PRN medications. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure wound treatment was provided only with a physician's order for two of the eight sampled patients (Patients 1 and 3). This failure had the potential for not providing appropriate, consistent, and quality care to thess patients. Findings: Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient was on oxygen at 4 liter per minute. The SN note dated 1/6/25, showed the patient was on oxygen at 2 liters per minute. The SN note dated 1/13/25, showed the patient was on oxygen at 2 liters per minute. * However, there was no documented evidence of a physician’s order for the use of oxygen. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. The agency P&P titled Physician Orders revised 7/8/09, showed drugs and treatments are administered by the agency staff only as ordered by the attending physician. Such order maybe given by telephone and shall be signed by the patients attending physician and legally authorized practitioner within his or her scope of practice within 30 working days. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8. The POC also showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. Report to physician any significant changes. SN to perform inspection of patients' lower extremities every visit and report any alteration in skin integrity to physician. a. Review of the SN visit notes dated 1/6/25 on the section of narrative showed the SN had performed skin assessment. The patient was assessed to have a wound to the left second toe. Cleanse the wound with normal saline, applied iodosorb covered and secured with rolled gauze and stretch netting. However, review of the clinical record failed to show documented evidenced of the physicians order for the treatment of the patients wound to the left second toe. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Cas Manager. The LVN Case Manage was asked if there was a physicians order for the wound treatment. The LVN Case Manager replied, no MD order. The LVN Case Manager was also asked if they can perform wound care without an order. The LVN Case Manager replied, no, we should have an order. The LVN Case Manager was informed and acknowledged the finding. Findings: The agency's P&P titled Physician Orders revised 7/8/09, showed drugs and treatments are administered by the agency staff only as ordered by the attending physician. Such order maybe given by telephone and shall be signed by the patients attending physician and legally authorized practitioner within his or her scope of practice within 30 working days. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1 and 2W8. The POC also cited SN to assess skin breakdown every visit, assess/evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection, report to the physician any significant changes, and inspection of the patient's lower extremities every visit and report any alteration in skin integrity to the physician. Review of the SN visit notes dated 1/6/25, showed the SN had performed skin assessment showing the patient had a wound to the left second toe. The SN performed wound care as follows: cleansed the wound with normal saline, applied iodosorb (a gel to treat wet wound), and covered and secured with a rolled gauze and stretch netting. However, review of the clinical record failed to show documented evidenced of the physicians order for the treatment provided to the patient's left second toe wound. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Cas Manager. The LVN Case Manage was asked if there was a physicians order for the wound treatment. The LVN Case Manager replied no MD order. The LVN Case Manager was also asked if they could perform a wound care without an order. The LVN Case Manager replied no, they should have an order. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient was on oxygen at 4 liter per minute. The SN note dated 1/6/25, showed the patient was on oxygen at 2 liters per minute. The SN note dated 1/13/25, showed the patient was on oxygen at 2 liters per minute. * However, there was no documented evidence of a physician’s order for the use of oxygen. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to revise and update the POC for two of eight sampled patients (Patients 5 and 8). This failure created the risk for not providing the necessary care and services to these patients. Findings: 1. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The physician’s order dated 12/26/24, showed Stage 1 pressure injury to both buttocks by cleaning with soap and water, apply Calmoseptine ointment (moisture barrier) daily or every diaper change. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The patient’s medication included erythromycin ophthalmic (eye antibiotic) 5 mg/gm one cm to affected eyelid margin once at HS for two weeks. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, pat dry, apply Calmoseptine ointment and leave open to air. The Medication Profile for the certification period from 12/30/24 to 2/27/25, showed a start date of 10/26/24 for erythromycin ophthalmic (eye antibiotic) 5 mg/gm one cm to affected eyelid margin once at HA for two weeks. * However, the POC was not revised to exclude the use of erythromycin ophthalmic and the POC was not revised to include the frequency of the buttocks wound treatment. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 2. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. Review of the Physicians Order dated 12/15/24, showed an order for CHHA visit 2W9. The POC, for the certification period from 12/15/24 to 2/12/25, cited CHHA visits 1W1, 2W6, 1W1. However, the POC was not revised to reflect the physicians order for CHHA visit 2W9. On 1/29/25 at 1344 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS stated the MD orders for CHHA 2W9 should have been followed, the POC was not revised to reflect the MD order. The Administrator/DPCS was informed and acknowledged the findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure PT services were timely for one of eight sampled patients (Patient 7). This failure created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: The agency's P&P titled Care Coordination Process revised 2/14/24, showed therapy services as well as medical social services when ordered will do initial evaluation 24-48 hours post receipt of referral. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The POC, for the certification period from 11/14/24 to 1/12/25, cited SN visits 1W1, 2W2, and 1W6. The POC also showed PT evaluation and treatment. Documentation showed the verbal SOC was received on 11/14/24. The PT Initial Evaluation dated 11/26/24, showed the PT had conducted a visit. * However, the initial PT evaluation visit was not timely as the visit occurred 11 days after the verbal SOC was received on 11/14/24. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide a written instruction outlining the visit schedule for three of eight sampled patients (Patients 1, 2, and 3). This failure had the potential for not providing the necessary information to these patients. Findings: #. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The POC, for the certification period from 12/9/24 to 2/6/25, cited SN visits 1W9 to perform assessment of patient with dementia. The physician’s order dated 1/5/25, showed SN visits daily x2, 2W2, and 1W2 for skilled assessment/observation of body systems, check vital signs, teaching/training, and follow-up. The physician’s order showed CHHA 2W5 to assist with ADLs. A joint home visit with CHHA 2 was conducted on 1/23/25 at 1016 hours, to Patient 1's home. Review of the patient’s home folder was conducted with the RCFE Administrator and CHHA 2. However, there was no documented evidence of written instructions outlining the SN and CHHA visit schedules. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 2's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The POC, for the certification period from 12/3/24 to 1/31/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The PT Evaluation dated 12/27/24, showed for the period from 12/3/24 to 1/31/25 included PT visits 1W6. A joint home visit with the PTA was conducted on 1/23/25 at 1300 hours, to Patient 2's home. Review of the patient’s home folder was conducted with the patient. However, there was no documented evidence of written instructions outlining the SN and PT visit schedules. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8 for assessment of patient with Type 2 Diabetes Mellitus with foot ulcer, non pressure chronic ulcer other part, right foot with necrosis of bone, type 2diabetes mellitus with diabetic neuropathy, unspecified type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage 1 to 4 unspecified chronic kidney disease, stage 3 venous insufficiency (chronic) (peripheral), other atherosclerotic native arteries of extremities, right leg, other specified arthritis, multiple sites contracture, right knee. The POC also showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. Report to physician any significant changes. SN to perform inspection of patients' lower extremities every visit and report any alteration in skin integrity to physician. A joint home visit with LVN 1 was conducted on 1/23/25 at 1000 hours, to Patient 3's home. Review of the patient’s home folder was conducted with LVN 1. However, there was no documented evidence of written instructions outlining the SN visit schedules. On 1/23/25 at 1127 hours, an interview and concurrent document review was conducted with the LVN 1. LVN 1 was asked if a visit schedule was available in the home folder. The LVN 1 replied, no. The LVN 1 was also asked if she uses a visit calendar. The LVN 1 replied, no, I don't use it. The LVN 1 was informed and acknowledged the finding. On 1/29/25 at 0940 hours, the finding was shared with the LVN Case Manager. The LVN Case Manager acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1 and 2W8 for assessment of the patient with Type 2 Diabetes Mellitus with foot ulcer, non pressure chronic ulcer other part, right foot with necrosis of bone, type 2diabetes mellitus with diabetic neuropathy, unspecified type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage 1 to 4 unspecified chronic kidney disease, stage 3 venous insufficiency (chronic) (peripheral), other atherosclerotic native arteries of extremities, right leg, other specified arthritis, and multiple sites contracture, right knee. The POC also showed SN to assess skin breakdown every visit and assess/evaluate wounds at each dressing change and PRN for signs and symptoms of infection, report to the physician any significant changes, perform inspection of the patients' lower extremities every visit, and report any alteration in skin integrity to the physician. A joint home visit with LVN 1 was conducted on 1/23/25 at 1000 hours, to Patient 3's home. Review of the patient’s home folder was conducted with LVN 1. However, there was no documented evidence of written instructions outlining the SN visit schedules. On 1/23/25 at 1127 hours, an interview and concurrent document review was conducted with LVN 1. LVN 1 was asked if a visit schedule was available in the home folder. LVN 1 replied, no. LVN 1 was also asked if she used a visit calendar. LVN 1 replied no. LVN 1 was informed and acknowledged the finding. On 1/29/25 at 0940 hours, the finding was shared with the LVN Case Manager. The LVN Case Manager acknowledged the finding. 2. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The POC, for the certification period from 12/9/24 to 2/6/25, cited SN visits 1W9 to perform assessment of the patient with dementia. The physician’s order dated 1/5/25, showed SN visits daily x2, 2W2, and 1W2 for skilled assessment/observation of body systems, checking vital signs, teaching/training, and follow-up. The physician’s order showed CHHA 2W5 to assist with ADL cares. A joint home visit with CHHA 2 was conducted on 1/23/25 at 1016 hours, to Patient 1's home. Review of the patient’s home folder was conducted with the RCFE Administrator and CHHA 2. However, there was no documented evidence of written instructions outlining the SN and CHHA visit schedules. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 2's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The POC, for the certification period from 12/3/24 to 1/31/25, cited SN visits 1W9 to perform assessment of the patient with hypothyroidism. The PT Evaluation dated 12/27/24, showed for the period from 12/3/24 to 1/31/25, to provide PT visits 1W6. A joint home visit with the PTA was conducted on 1/23/25 at 1300 hours, to Patient 2's home. Review of the patient’s home folder was conducted with the patient. However, there was no documented evidence of written instructions outlining the SN and PT visit schedules. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patients received care and services as per the written plan of care for five of eight sampled patients (Patients 3, 4, 5, 6, and 8). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. #. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, apt dry, apply Calmoseptine (moisture barrier) ointment and leave open to air. The SN note dated 12/31/24, 1/3, 1/7, and 1/10/25, showed SN provided treatment to Stage 1 buttocks pressure injury. Documentation showed cleansed with NS, patted dry with gauze, applied A&D cream (moisture barrier) and Calmoseptine on the redness area, which was not consistent with the POC. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 8/2/24. The patient was certified for home health services during the certification periods from 10/1/24 to 11/29/24 and 11/30/24 to 1/28/25. The POC, for the certification period from 11/30/24 to 1/28/25, cited SN visits 2W2 and 1W6. Documentation showed to notify the physician if pulse is greater than 100 or less than 60 and the systolic BP greater than 160 mm Hg or less than 90 mm Hg. The SN note dated 12/22/24, showed the patient’s pulse was 59 and the BP was 164/85 mm Hg. * However, there was no documented evidence the physician was notified regarding the patient’s pulse less than 60 and systolic BP greater than 160 mm Hg. On 1/29/25 at 0905 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8. The POC showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. The wound care includes to leave adaptic and steri-strip in place. Change outer dressings only. SN to cover adaptic with abdominal pad, secure with rolled gauze and tape. Change on Friday and Monday. Report to physician any significant changes. SN to perform inspection of patients' lower extremities every visit and report any alteration in skin integrity to physician. * Review of the SN visit notes dated 1/6/25 on the section of narrative showed the SN had performed wound assessment and treatment. The patient was assessed to have a wound to the left second toe. However, review of the clinical record failed to show documented evidenced of the physician was notified of the wound on the patients left second toe as ordered in the POC. * Review of the SN visit notes dated 1/1, 1/6, 1/10, 1/13, 1/17 and 1/20/25, showed the SN had performed wound treatment to the patients right forefoot. However, the SN failed to performed wound assessments every visit as ordered in the POC. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. Cross ref. G- 984 b. The POC, for the certification period from 10/26/24 to 12/24/24, cited SN visits 2W9. The POC showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. The wound care includes cleanse the right forefoot wound with normal saline solution, pat dry, apply Prisma into superior hole, then Endoform on wound bed, wrap with rolled gauze, change on Monday and Friday. Report to physician any significant changes. SN to perform inspection of patients' lower extremities every visit and report any alteration in skin integrity to physician. The POC also showed to to notify physician for the systolic BP greater than 160 or less than 90, diastolic BP greater than 90 or less than 60 and oxygen saturation less than 90. Review of the SN visit notes dated 10/28, 11/4, 11/11, 11/28, 11/25, 12/2, 12/9 and 12/16/24 showed the SN had performed body system assessment and wound dressing change to the patients right forefoot. However, the SN failed to performed wound assessment the patients right forefoot as ordered in the POC. * Review of the SN notes dated 11/9 and 12/6/24, showed the SN had performed vital signs assessment. The vital signs showed a BP reading of 178/77 sitting. However, review of the clinical record failed to show documented evidenced of the physician was notified of the elevated BP as ordered in the POC. In addition, review of the SN notes dated 11/1/24, showed the SN had performed vital signs assessment. However, the oxygen saturation was left blank. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient's OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. a. The POC, for the certification period from 10/28/23 to 12/26/23, cited SN visits 1W9. The POC showed SN to assess patient with unspecified dementia, unspecified severity without behavior/psychiatric/mood/anxiety, hypotension, unspecified exocrine pancreatic insufficiency, vitamin B12 anemia, unspecified, vitamin D deficiency, and unspecified urge incontinence. The POC includes SN to check vital signs every visit and notify physician if the oxygen saturation less than 90%. The POC also includes SN to assess for changes in neurological status every visit. Review of the SN notes dated 11/4 and 11/18/23, showed the SN had performed neurological assessment. However, the section for the orientation to person, place and time was left blank. Further review of the SN visit notes dated 11/4, 11/11 and 11/1/23, showed the SN had performed vital signs assessment. However, the section for the oxygen saturation was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. b. The POC, for the certification period from 8/29/23 to 10/27/23, cited SN visits 1W9. The POC showed SN to assess patient with exocrine pancreatic insufficiency, vitamin B12 deficiency anemia, unspecified, hypertensive heart disease without heart failure, unspecified dementia, unspecified severity, without behavior/psychiatric/mood/anxiety, vitamin D deficiency, unspecified low back pain and unspecified urge incontinence. The POC includes SN to check vital signs every visit and notify physician if the oxygen saturation less than 90%. The POC also includes SN to assess for changes in neurological status every visit. Review of the SN notes dated 9/2, 9/9, 9/16, 9/23, 9/30, 10/7, 10/14 and 10/21/23 showed the SN had performed neurological assessment. However, the section for the orientation to person, place and time was left blank. Further review of the SN visit notes dated 9/2, 9/9, 9/16, 9/23, 9/30, 10/7, 10/14 and 10/21/23, showed the SN had performed vital signs assessment. However, the section for the oxygen saturation was left blank. On 1/29/25 at 1007 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 3. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. a. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2, 1W7 for assessment of patient with Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified cervical disc disorder with myelopathy, unspecified cervical region, paroxysmal atrial fibrillation, multiple myeloma not having achieve remission, mixed hyperlipidemia, gastro - esophageal reflux disease without esophagitis, essential (primary) hypertension, muscle wasting and atrophy, NEC multiple sites, slow transit, constipation, vitamin B12 deficiency anemia, unspecified. The POC includes SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit. Review of the SN notes dated 12/20/24, 1/23, 12/28/24, 1/6/25, 1/13 and 1/20/25 showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with patient's activity or movement = less often than daily, - the primary site = neck, - pain intensity = 3, - current pain management and effectiveness was blank and - what makes the pain worse = moving. However, the SN failed to assess the patients current pain medication and effectiveness every visit as the section was left blank. b. The POC, for the certification period from 12/15/24 to 2/12/25, cited PT for strengthening and safety. Review of the Physicians Order dated 12/18/24, showed an order for PT to evaluate/ instruct/perform home safety, therapeutic exercises, ROM exercises, strengthening exercises, gait training, balance drills, transfers training and set up home exercise program. PT visits 1W2, 2W5. Review of the clinical record showed the PT performed an evaluation on Week 1 (from 12/15 to 12/21/24) on 12/18/24. However, review of the clinical record failed to show documented evidenced of the PT visits on Week 2 (from 12/22 to 12/28/24) as per physicians order. On 1/29/25 at 0935 an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and or caregiver was provided education related to anticoagulant medication and oxygen therapy as per the plan of care for one of eight sampled patients (Patient 5). This failure had the potential for not providing the necessary care and services to these patients. Findings: Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, instructed PCG on flu precautions and oxygen therapy and management. The SN note dated 1/6/25, showed teaching done on how to care for patient with oxygen. However, there was no documented evidence the POC included patient/PCG education on oxygen therapy and management. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2, 1W7 for assessment of patient with Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified cervical disc disorder with myelopathy, unspecified cervical region, paroxysmal atrial fibrillation, multiple myeloma not having achieve remission, mixed hyperlipidemia, gastro - esophageal reflux disease without esophagitis, essential (primary) hypertension, muscle wasting and atrophy, NEC multiple sites, slow transit, constipation, vitamin B12 deficiency anemia, unspecified. The POC includes SN to instruct the patient/caregiver on precautions for high risk medications to anticoagulants/anti-platelets. The Medication Profile for the certification period from 12/15/24 to 2/12/25, showed the patient's medications included Eliquis (anticoagulant) 5 mg one tablet PO BID. Review of the SN notes dated 12/20/24, 1/23, 12/28/24, 1/6/25, 1/13 and 1/20/25 showed the SN had performed body system assessment. However, review of the SN visit notes failed to show documented evidenced of the patient/PCG education related to the use of Eliquis (anticoagulant) was provided as instructed in the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was asked if there was an education related to anticoagulant use. The Administrative Assistant/LVN replied, the precautions were not discussed on the SN visit notes. The Administrative Assistant/LVN was informed and acknowledged the finding. Findings: 1. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2 and1W7 for assessment of the patient. The POC included SN to instruct the patient/caregiver on precautions for high risk medications to anticoagulants/antiplatelets. The Medication Profile for the certification period from 12/15/24 to 2/12/25, showed the patient's medications included Eliquis (anticoagulant) 5 mg one tablet PO BID. Review of the SN notes dated 12/20/24, 1/23, 12/28/24, 1/6/25, 1/13, and 1/20/25, showed the SN had performed body system assessment. However, review of the SN visit notes failed to show documented evidence of the education related to the use of Eliquis (anticoagulant) was provided to the patient/PCG as instructed in the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was asked if there was an education related to anticoagulant use. The Administrative Assistant/LVN stated the precautions were not discussed on the SN visit notes. The Administrative Assistant/LVN was informed and acknowledged the finding. 2. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the SN instructed PCG on flu precautions and oxygen therapy and management. The SN note dated 1/6/25, showed teaching was done on how to care for the patient with oxygen. However, there was no documented evidence the POC included the patient/PCG education on oxygen therapy and management. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for seven of eight sampled patients (Patients 1, 2, 3, 5, 6, 7, and 8). This failure had the potential for substandard healthcare outcomes to these patients. #. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Physician’s Order dated 1/5/25, showed SN visits daily x2, 2W2, and 1W2 for skilled assessment/observation of body systems, check vital signs, teaching/training, and follow-up. The physician’s order included pureed diet. The SN note dated 1/6/25, showed renal heart healthy pureed diet. The SN note dated 1/13/25, showed renal diet. * However, the diet in the physician’s order was not consistent with the SN notes dated 1/6 and 1/13/25. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 2's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The POC, for the certification period from 12/3/24 to 1/31/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC included to administer D5 NS 500 ml/one hour for two hours via peripheral line once a month for one year as directed by the physician. The OASIS-E Start of Care dated 12/3/24, showed D5 1/2 NS one liter was started to run for two hours. The SN note dated 1/3/25, showed D5 1/2 NS one liter was started and completed after two hours. The Delivery Ticket from the pharmacy dated 12/2/24 and 12/30/24, showed D5 NS was delivered. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. The Administrator/DPCS stated the RN did not administer D5 1/2 NS. They were informed and acknowledged the finding. * However, the information of the intravenous fluid concentration was not accurately documented in the SN notes dated 12/3/24 and 1/3/25. #. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Recertification dated 12/26/24, showed the patient had a Stage 1 right and left buttock pressure injury. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, apt dry, apply Calmoseptine (moisture barrier) ointment and leave open to air. There was no documented evidence the patient’s Stage 1 right and left buttock pressure injury was measured on Week 3 (1/12/25 to 1/18/25). On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. RN 2 stated the patient’s Stage 1 right and left buttock pressure injury was healed on Week 3. * However, RN 2 failed to document the patient’s Stage 1 right and left buttock pressure injury was healed on Week 3 On 1/29/25 at 0934 hours, the Administrator/DPCS, Biller, and RN 2 were informed and acknowledged the finding. #. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The POC, for the certification period from 11/14/24 to 1/12/25, showed the patient’s nutritional requirements included no added salt mechanical soft heart healthy. The SN note dated 11/20, 11/22, and 11/27/24, showed regular diet, which was not consistent with the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 10/26/24 to 12/24/24, cited SN visits 2W9 for assessment of patient with Type 2 Diabetes Mellitus with foot ulcer, non pressure chronic ulcer other part, right foot with necrosis of bone, type 2diabetes mellitus with diabetic neuropathy, unspecified type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage 1 to 4 unspecified chronic kidney disease, stage 3 venous insufficiency (chronic) (peripheral), other atherosclerotic native arteries of extremities, right leg, other specified arthritis, multiple sites contracture, right knee. The POC includes SN to assess blood sugar via finger stick every visit prior to insulin administration. The POC also includes to notify physician for fasting blood sugar greater than 300 or less than 60, random blood sugar greater than 300 or less than 60 and diastolic BP greater than 160 or less than 90 and systolic BP greater than 90 or less than 60. a. Review of the SN notes showed the SN had assess the patients blood sugar level on the following dates: -On 12/9 - blood sugar was 91, -On 12/13 - blood sugar was 127 and -On 12/16/24 - Blood sugar was 118. However, on the narrative section of the notes showed patient was not able to check her blood sugar but refused for SN to check the patients blood sugar which was inconsistent. b. Review of the SN notes showed the SN had assess the patients blood pressure on the following dates: -On 12/2 - BP was 120/60, -On12/9 - BP was 130/60, -On 12/13 - BP was 112/60 and -On 12/16/24 - BP was 130/80. However, on the narrative section of the notes showed patient was documented as 178/77which was inconsistent. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The CHHA Care Plan dated 8/26/23 for the certification periods from 8/29/23 to 10/27/23, showed for the CHHA vital signs notification parameters. The vital signs parameters includes the following for pulse and respiration: - pulse - more than 24 and less than 12 and - respiration - more than 100 and less than 60. However, the parameters for pulse rate and respiratory rate were inaccurate. In addition, review of the CHHA visit notes dated 8/29, 9/2, 9/5, 9/8, 9/12, 9/19, 9/22, 9/26, 10/3, 10/6, 10/10, 10/10, 10/13, 10/17,10/20,10/24 and 10/27/23, showed the CHHA check the vital signs. However, the physician notifications for the pulse and respiratory rate parameters were inaccurate. On 1/29/25 at 1007, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 3. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2, 1W7 for assessment of patient with Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified cervical disc disorder with myelopathy, unspecified cervical region, paroxysmal atrial fibrillation, multiple myeloma not having achieve remission, mixed hyperlipidemia, gastro - esophageal reflux disease without esophagitis, essential (primary) hypertension, muscle wasting and atrophy, NEC multiple sites, slow transit, constipation, vitamin B12 deficiency anemia, unspecified. The POC also includes SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit. a. Review of the SN notes dated 12/20/24, 1/13/25 showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with patient's activity or movement = less often than daily, - the primary site = neck, - pain intensity = 3, - current pain management and effectiveness was blank and - what makes the pain worse = moving. However, on the section of the narrative notes showed the SN documented patient denies pain and discomfort at this time which was inconsistent. b. Review of SN notes dated 12/28, 1/20/25 showed the SN had performed cardiovascular assessment. The assessment includes a check marked on the section of WNL (within normal limits) and on the section of edema. The edema was located on bilateral lower extremity, 2+. However, on the section of narrative notes showed the SN documented no swelling noted which was inconsistent. On 1/29/25 at 0935 an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings.

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 interview and record review, the agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of eight sampled patients (Patient 8). This failure had the potential for substandard health outcomes to this patient. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. Review of the clinical record for Patient 8 showed the LVN did not provide services in accordance with the POC for this patient. Cross reference to G710, example #4. The LVN Supervisory Note dated 1/22/25, showed the RN had conducted a supervisory visit and the LVN followed the plan of care. * However, the RN failed to identify the LVN did not provide services in accordance with the POC. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and clinical record review, the agency's Administrator failed to be responsible for the day-to-day operations as the agency's P&P related to the CHHA 12 hours in service training was completed for CHHA 3. This failure had the potential for not providing quality of care and services to the patients receiving services from the HHA. The agency's P&P titled In-Service Training undated, showed the agency provides continuous in-service training program for all employees. The purpose was to provide employee competence, improve patient care and to improve employee efficiency. The procedures includes the documentation of attendance in in-service training session, and or completion of in-service training exercises is retained in the in-service training files with cross filing in the personnel record of the individual staff participating. All CHHA's must have 12 hours of in-service per year. Review of the agency's binder for 2024 In-service was initiated on 1/28/25. The binder showed the in-services and the post test trainings provided to the CHHA's monthly. The binder also included the staff attendance form. The attendance form showed the agency had 4 CHHAs. Review of the CHHA 3's personnel file showed the hiring date was 9/22/17. Review of the agency's In-service training Binder showed CHHA 3's in-services trainings. CHHA 3 attended an hour of in-service trainings for the months of January, February, March, April, May, June, July, August, September, and November 2024. However, review of the In-service training Binder failed to show documented evidenced of CHHA 3 attended the trainings for the month of October and December 2024 to complete the 12 hours in-service as per the agency's P&P. On 1/19/25 at 0900 hours, an interview and concurrent document review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency's Administrator failed to be responsible for the day-to-day operations related to CHHA in-service training documentation. This failure had the potential for not providing quality of care and services to the patients receiving services from the HHA. Review of the Job Description for the agency's Administrator signed and dated 6/10/24, showed the performance, responsibilities and standards includes to ensure quality and safe delivery of services such as developed and implemented written agency policy and procedures reflect safety and quality delivery of home health services. The agency's P&P titled In- Service Training, undated, showed the agency provides continuous in-service training program for all employees. The purpose was to provide employee competence, improve patient care and to improve employee efficiency. The procedures includes the documentation of attendance in in-service training session, and or completion of in-service training exercises is retained in the in-service training files with cross filing in the personnel record of the individual staff participating. Review of the agency's binder for CHHA 2024 In-service was initiated on 1/28/25. The binder showed the in-services and the post test trainings provided to the CHHA's monthly. The binder also included the staff attendance form. The attendance form showed the agency had 4 CHHAs. However, the training exercises for the months of January, February, March, April, May, June, July and August 2024 were left blank. In addition, there were no documented evidenced of the training exercises provided for the month of October and December 2024 as per the agency's P&P. On 1/19/25 at 0900 hours, an interview and concurrent document review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written patient care instructions for the CHHA was developed by the RN who was responsible for the supervision of the CHHA for three of eight sampled patients (Patients 1, 5, and 8). This failure had the potential for not addressing the care needs for these patients. Findings: 1. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Aide Care Plan for the certification period dated 12/9/24 to 2/6/25, showed HA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 2. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The Aide Care Plan for the certification period dated 12/30/24 to 2/27/25, showed HA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. Review of the Aide Care Plan dated 12/15/24 cited aide visit 2W9 for the assessment of functional limitations, vital sign notification to include no bowel movement in 3 days, vital signs, activity for ambulation and transfer and personal care every visit. The care plan also includes the section for elimination. However, the care plan failed to show documented evidenced of the frequency to record bowel movement as the section was left blank. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. Findings: 1. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Aide Care Plan for the certification period dated 12/9/24 to 2/6/25, showed CHHA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 2. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The Aide Care Plan for the certification period dated 12/30/24 to 2/27/25, showed CHHA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. Review of the Aide Care Plan dated 12/15/24 cited CHHA visit 2W9 for the assessment of functional limitations, vital sign notification to include no bowel movement in 3 days, vital signs, activity for ambulation and transfer and personal care every visit. The care plan also included the section for elimination. However, the care plan failed to show documented evidenced of the frequency to record bowel movement as the section was left blank. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure care and services were provided in accordance with the care plan for two of eight sampled patients (Patient 5 and 6). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. 1. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The Aide Care Plan dated 8/26/23, for the certification periods from 8/29/23 to 10/27/23, cited CHHA 2W9. The Aide Care plan showed the assignment for the CHHA every visit. The assignment includes functional limitations, DME, supplies, activities permitted, elimination, household, personal care, vital sign notification and vital signs every visit. Review of the CHHA visit notes dated 9/29/23, showed the CHHA performed the care plan assignment. However, the section for vital signs - blood pressure, temperature, pulse and respiration were left blank. On 1/29/25 at 1007 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the finding. 2. Review of Patient 5's closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited CHHA 1W1, 2W6, and 1W1 for assistance with ADL/IADL cares. Review of the Aide Care Plan dated 12/15/24, cited CHHA visit 2W9 for the assessment of functional limitations, vital sign notification to include no bowel movement in 3 days, vital signs, activity for ambulation and transfer and personal care every visit. However, review of the clinical record failed to show documented evidence of the CHHA visits during Week 2 (from 12/22 to 12/28/24) as cited in the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. On1/29/25 at 1344 hours, a follow -up interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS stated the patient refused a CHHA visit during the first two weeks; however, there was no documentation found in the clinical record. The Administrator/DPCS was informed and acknowledged the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency's RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for one of eight sampled patients (Patient 6). This failure had the potential for substandard health outcomes to this patient. The agency's P&P titled Home Health Aide Services, undated, showed the procedures includes the registered nurse makes a supervisory visit to the patients residence at least every two weeks following the policy and procedure. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The POC, for the certification period from 10/28/23 to 12/26/23, showed CHHA visits 2W9. Review of the CHHA notes dated 10/31, 11/3, 11/6, 11/10, 11/14, and 11/21/23, showed the CHHA provided care and services as ordered. However, there was no documented evidence the agency's RN provided supervision to the CHHA no less frequently than every 14 days. On 1/29/25 at 1018 hours, an interview and concurrent closed clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was asked about the frequency of the supervisory visit for the CHHA. The LVN Case Manager stated the supervisory visit was conducted every two weeks. The LVN Case Manager was also asked when the supervisory visit should be conducted. The LVN Case Manager replied they should be on 11/1 and 11/15/23, but we missed two supervisory visits. The LVN Case Manager was informed and acknowledged the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency's Administrator failed to be responsible for the day-to-day operations related to the written agreements with the contracted RD, PT, and OT. This failure had the potential for not providing quality of care and services to the patients receiving services from the HHA. The agency’s Job Description for Administrator dated 6/10/24, showed the performance responsibilities and standards included ensuring compliance of agency operations with federal, state, and local rules and regulations. Title 22 Section 74719 (Services Arranged by Agreement), showed the following: (b) The agreement shall include at least the following: (1) The nature and scope of the services to be provided; (2) The rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; (3) The role, if any, of the agency and the contracted individual or agency in: (A) The patient admission process, (B) Patient assessment, (C) The development, review, and revision of the plan of treatment or plan of care, (D) Patient care conferences, (E) The scheduling of visits or hours, (F) Discharge planning; (4) The submission to the agency of documentation of services provided; (5) The responsibility of the contracted individual or agency to adhere to applicable agency policies, including personnel qualifications; (6) The procedures for determining charges and reimbursement; and (7) The term of the agreement and the conditions for its renewal or termination. (c) Agreements shall be reviewed and revised as necessary. 1. Review of the written agreements between the agency and contracted RD was initiated on 1/28/25. The agency's written agreement with the contracted RD did not include the role of the agency and contracted RD for the patient admission process, scheduling of visits or hours, discharge planning, the submission to the agency of documentation of services provided. 2. Review of the written agreements between the agency and contracted PT and OT was initiated on 1/28/25. The agency's written agreement with the contracted PT and OT did not include the role of the agency and the contracted PT and OT for the patient admission process, patient care conferences, and discharge planning. On 1/29/25 at 1011 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's P&Ps were implemented related to the following: No discharge summary sent to the physician within five business days for one of eight sampled patients (Patient 6). The performance evaluation and skills competency were not completed for CHHA 3. The pre-employment health screening and hepatitis B Vaccine were not in the personnel files for CHHAs 1 and 3 and LVNs 1 and 3. Wound assessments were not performed for Patients 3 and 8 as per the agency's P&P. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. #. Review of Patient 8's clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Recertification dated 12/26/24, showed the patient had a Stage 1 right and left buttock pressure injury. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, apt dry, apply Calmoseptine (moisture barrier) ointment and leave open to air. * However, there was no documented evidence the patient’s Stage 1 right and left buttock pressure injuries were measure on Week 1 (12/30/24 to 1/4/25) and Week 2 (1/5/25 to 1/11/25). On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. The agency’s P&P titled Discharge Summary reviewed 10/29/06, showed a discharge summary will be completed within seven days of the discharge date. The purpose includes to document instructions given to the client/family regarding medications. The procedure includes a copy will be sent to the physician upon request for example: Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient's OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. However, the agency's P&P failed to indicate the timeline of the discharge summary needed to be sent to the physician within five business days from discharge as per state regulation. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Casa Manager was asked if the discharge summary was sent to the physician within 5 business days from discharge. The LVN Case Manager reviewed their files and replied, no documentation as to when the discharge summary was sent to the physician. The LVN Case Manager was also asked if the policy was updated to reflect the timeline of 5 business days from discharge to be sent to the physician. The LVN/Case Manager replied, no, we need to update our P&P. The LVN Case Manager was informed and acknowledged the finding. cross ref. G - 1022 2. Review of the agency's P&P showed the following were not implemented: a. The agency's P&P titled Health Screening revised 11/11/09, showed the purpose was to ensure safe health status of each worker to perform essential job functions. The procedure included a pre-employment physical examination will be performed by physician or nurse practitioner as mandated by state, federal and local laws. Health screening will occur after a conditional offer of employment is made within six months prior to employment or within 15 days of assuming employment). A complete physical examination will be required at least every two years. The written physical examination shall be signed by the person who performed the assessment, verify that employee is free from health conditions which would interfere with the employees ability to performed assigned duties, contained verification that the employee is free from signs and symptoms of infectious disease and provide for a tuberculosis screening which shall be administered to all employees who have direct patient contact and annually thereafter using 5 TU (Tuberculin units) Protein Derivative (PPD) tuberculin skin test. Hepatitis B Vaccine and vaccination series shall be made available to all employees who are at risk for exposure to blood and body fluids. Acceptance or refusal of the vaccine must be documented. * Review of the CHHA 3's personnel file showed the hiring date was 9/22/17. The employee's latest physical examination was dated 7/13/22 and 9/20/22. However, there was no documented evidence of the physical examination was conducted after two years as per agency's P&P. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. * Review of LVN 1's personnel file showed the hiring date was 9/1/23. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. Further review of the LVN 1's file failed to show documented evidenced of the pre-employment physical was performed prior to the hiring date. * Review of LVN 3's personnel file showed the hiring date was 7/30/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. * Review of CHHA 1's personnel file showed the hiring date was 1/6/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. * Review of LVN 1's personnel file showed the hiring date was 9/1/23. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. Further review of the LVN 1's file failed to show documented evidenced of the pre-employment physical was performed prior to the hiring date. * Review of LVN 3's personnel file showed the hiring date was 7/30/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. * Review of CHHA 1's personnel file showed the hiring date was 1/6/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. b. The agency's P&P titled Employee Evaluation undated, showed agency staff members are given appraisals of employment after 90 days after the date of hire and annually based on date of hire. Appraisals of skills are given every three years and as necessary. * Review of the CHHA 3's personnel file showed the hiring date was 9/22/17. The employee’s performance evaluation was conducted annually. However, there was no documented evidenced of the performance evaluation was conducted for the year 2023. In addition, the latest skills competency were conducted on 9/20/20. However, there was no documented evidenced of the skills competency was conducted for the year 2023 as per P&P. On 1/29/25 at 0905 hours, an interview and concurrent document review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the personnel files and acknowledged the findings. * Review of LVN 3's personnel file showed the hiring date was 7/30/24. Review of the Skills Checklist and Performance Evaluation dated 7/30/24 showed the sections for Self-assess, Preceptor assess and Date. The section on Self assess included the following: -The medication administration techniques: oral, rectal, IM, Sub-q, inhaler/nebulizer, sublingual and Gtts -ear and eye, -Emergency care: call 911 and CPR, -1-800 Hotline # 1-800-228-5234: number and hours of operation, complaints, information on Advance Directives and information on Home Health Care and -Medications: route, frequency, dosage & indication, drug, food interaction, home monitoring program, side effects and adverse reactions. However, on the section for the Preceptor assess and date was left blank. In addition, the section for the employee was dated 1/5/24. However, the employee signature was left blank. Moreover, the evaluator signature and date was left blank. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. c. The agency's P&P titled Clinical Documentation revised 7/8/09 showed all wounds will be assessed with each visit and must include the following: size measured weekly and PRN, site, location, drainage, cleansing/irrigation and or rinsing medium, medication applied, type of packing, type of dressing, progress or non progress in healing, other notation as appropriate and complete weekly skin wound assessment form and treatment record. Review of Patient 3's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8. The POC also showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. Report to physician any significant changes. SN to perform inspection of patients' lower extremities every visit and report any alteration in skin integrity to physician. Review of the SN visit notes dated 1/6/25 on the section of narrative showed the SN had performed skin assessment. The patient was assessed to have a wound to the left second toe. However, review of the clinical record failed to show documented evidenced of a complete wound assessment to the patient left second toe was performed as per P&P. In addition, review of the SN notes dated 12/26/24 and 1/3/25, showed the SN had performed wound assessment and treatment to the patients’ right forefoot. However, review of the SN visit notes dated 1/1, 1/6, 1/10, 1/13, 1/17 and 1/20/25 failed to show documented evidenced of the complete wound assessment to the patients right forefoot was performed every visit as per P&P. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's CHHA prepared accurate visit notes for one of eight sampled patients (Patient 1). This failure had the potential for substandard healthcare outcomes for this patient. Findings: Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Aide Care Plan for the certification period dated 12/9/24 to 2/6/25, showed CHHA visits 2W9. The OASIS-E Transfer dated 12/28/24, showed the patient was transferred to an inpatient facility. The CHHA note dated 12/30/24, showed a visit was conducted. Documentation showed the patient’s BP was 123/67 mmHg, pulse was 72 beats per minute, respiration was 17 breath per minute, and temperature was 97.8 degrees Fahrenheit. Documentation showed CHHA 2 performed the following tasks: bed bath completed, assisted to dressing, combed hair, peri and incontinent care performed, hair shampooed, and assisted with transfer. Documentation showed the patient’s skin was clean and dry. Documentation showed CHHA 2 digitally signed the CHHA note. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient had inpatient hospitalization due to influenza. * Documentation showed CHHA 2 had conducted a visit on 12/30/24, after the patient was transferred to an inpatient facility dated 12/28/24. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. The Administrator/DPCS stated CHHA 2 did not conduct a CHHA visit on 12/30/24. On 1/29/25 at 0900 hours, the Administrator/DPCS, Biller, and RN 2 were informed and acknowledged the finding.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the completed discharge summaries were sent to the primary care practitioner within five business days of the discharge date for two of two sampled discharged patients (Patients 6 and 7), and the completed transfer summary for one of eight sampled patients (Patient 1). These failures had the potential for not providing the necessary care and services to these patients after discharge from the HHA. Findings: Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E Transfer dated 12/28/24, showed the patient was transferred to an inpatient facility. * However, there was no documented evidence the medications that the patient was on at the time of transfer was included in the transfer summary. In addition, there was no documented evidence the transfer summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient within 2 business days of becoming aware of an unplanned transfer. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The Discharge Summary dated 10/10/25, the reason for discharged was due to being hospitalized. * However, there was no documented evidence the discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA within 5 business days of the patient's discharge. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. The agency P&P titled Care Coordination Process revised 2/14/14, showed the purpose is to ensure proper handling of the patient throughout the entire process of patient care from initial intake and completion at discharge. The procedures included discharge. The discharge order and a discharge summary are sent to the attending MD. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient's OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. However, there was no documented evidence the discharge summary was sent to the physician within five business days of the patient's discharged. In addition, review of the OASIS discharge dated 11/24/23, included a discharge summary. However, the medications list was not included in the discharge summary. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Casa Manager was asked if the discharge summary was sent to the physician within 5 business days from discharge. The LVN Case Manager reviewed their files and replied, no documentation as to when the discharge summary was sent to the physician. The LVN Case Manager was also asked if the discharge summary needed to include the list of medications. The LVN Case Manager replied, no per P&P. The LVN Case Manager was informed and acknowledged the findings. The agency P&P titled Care Coordination Process revised 2/14/14, showed the purpose is to ensure proper handling of the patient throughout the entire process of patient care from initial intake and completion at discharge. The procedures include discharge. The discharge order and discharge summary are sent to the attending MD. 1. Review of Patient 6's closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient's OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. However, there was no documented evidence the discharge summary was sent to the physician within five business days of the patient's discharged. In addition, review of the OASIS discharge dated 11/24/23, included a discharge summary. However, the medications list was not included in the discharge summary. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Casa Manager was asked if the discharge summary was sent to the physician within 5 business days from discharge. The LVN Case Manager reviewed their files and replied, no documentation as to when the discharge summary was sent to the physician. The LVN Case Manager was also asked if the discharge summary needed to include the list of medications. The LVN Case Manager replied no. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 1's clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E Transfer dated 12/28/24, showed the patient was transferred to an inpatient facility. * However, there was no documented evidence the medications that the patient was on at the time of transfer was included in the transfer summary. In addition, there was no documented evidence the transfer summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient within 2 business days of becoming aware of an unplanned transfer. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The Discharge Summary dated 10/10/25, showed the reason for discharge was due to being hospitalized. * However, there was no documented evidence the discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient after discharge from the HHA within 5 business days of the patient's discharge. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Partial Extended Recertification surveys. Representing the California Department of Public Health: Surveyors 39796, HFEN; 39539, HFEN; and 39210, HFEN. The survey team entered the HHA on 1/4/22 at 0900 hours. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: HHA: Home Health Agency LVN: Licensed Vocational Nurse P&P: Policy and Procedure

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan was reviewed and updated at least every two years. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's emergency preparedness P&P and plan was conducted on 1/11/22. The agency's P&P titled Emergency Preparedness Plan showed the P&P was last reviewed on 10/29/06. The agency's P&P titled Emergency Preparedness Policy showed the P&P was last reviewed on 8/30/19. However, there was no documented evidence showing the agency's Emergency Preparedness P&Ps were reviewed and updated at least every two years. On 1/11/22 at 0900, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure their comprehensive emergency preparedness program was based on community based risk assessment, utilizing an all hazards approach. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 1/11/22. The agency's P&P tiled Emergency Preparedness Policy revised date 8/30/19, showed an environmental hazards assessment was completed. However, the agency's emergency preparedness plan failed to include a facility based risk assessments and strategies for addressing hazards or emergency events identified by the facility and community risk assessments. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure their emergency P&P and plan included a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials. This created the potential risk of not maintaining an integrated response during a disaster or emergency situation. Review of the agency's P&P on emergency preparedness was conducted on 1/11/22. The agency's Emergency Preparedness Policy reviewed 8/30/19, showed in the event of an evacuation, the Red Cross and local authorities will be notified by the Director of high risk patients. However, the agency's emergency preparedness P&P and plan failed to describe the agency's process in engaging and coordinating with the local healthcare systems, local and state health departments, and federal agency staff. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to establish a comprehensive emergency preparedness program based on the risk assessment and ensure to review every two years. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's emergency preparedness P&P and plan was conducted on 1/11/22. The Emergency Preparedness Policy showed a reviewed date of 8/30/19, and the Emergency Preparedness Plan showed a reviewed date of 10/29/06. However, there was no documented evidence the agency's emergency preparedness plan and P&P were based on facility and community based risk assessments, and reviewed and updated at least every two years. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the findings.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to establish and maintain a comprehensive emergency preparedness program including plans for the patients during a natural and man made disaster. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 1/11/22. The agency's emergency preparedness P&P and plan failed to describe the agency's comprehensive approach to ensure all patients to have an individualized plan in the event of an emergency and be included in the patient's comprehensive assessment. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan and P&P included procedures to inform the state and local emergency officials about the patients in need of evacuation from their residences due to an emergency situation. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 1/11/22. The Emergency Preparedness Policy reviewed 8/30/19, showed in the event of a weather emergency, or lack of public transportation, every effort will be made by the agency to provide vehicles or transportation to employees to the patient homes. Local police, highway patrol, and sheriffs offices will be notified of patients with specific and imminent needs requiring services from the agency. However, the agency's emergency preparedness P&P and plan failed to describe when and how information will be communicated to the emergency officials in the event a patient needed the evacuation at any time due to an emergency situation based on the patient's medical, psychiatric condition and home environment. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan included procedures to follow up with on-duty staff and patients, to determine services needed and procedures to inform state and local officials of any on-duty staff or patients they are unable to contact. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness and plan was conducted on 1/11/22. The agency's Emergency Preparedness Plan P&P reviewed 10/29/06, showed in the event the management staff are unable to contact the skilled nursing staff due to widespread communication failure, the nurses are expected to meet the urgent needs of their patients according to priority needs to the best of their ability without compromising their safety. However, the agency's Emergency Preparedness Plan P&P did not include the procedures to follow up with any on-duty staff or patients they are unable to contact, or procedures to communicate with state and local officials of any on duty staff or patients they are unable to contact. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the above findings.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness P&P addressed a system of medical documentation that protected confidentiality of the patient information, and secured and maintained availability of records. This created the potential risk of not protecting the patient's confidential information during the emergency. Review of the agency's emergency preparedness P&P was conducted on 1/11/22. The agency's emergency preparedness P&P showed the agency's DPCS will pick up the claims records, backup tapes, and records pending filing in the medical records room. In addition the computer system will be secured with the server shut down. However, the P&P did not address a system of medical documentation that protected confidentiality of patient information, and secured and maintained availability of records. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness P&P addressed the use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Review of the agency's P&P on emergency preparedness was conducted on 1/11/22. The agency's emergency preparedness P&P showed it will determine staffing availability and limitations including assistance available from external staffing agencies and in the event staff is not available, and the agency is not able to provide care, the patient will be directed to seek care at local emergency services, the red cross, utilize the public ambulance services, any available hospital emergency room, or at any physician offices or clinics. However, the agency's emergency preparedness P&P and plan did not include the use of volunteers in an emergency, and other emergency staffing strategies to address surge needs, including which external staffing agencies to be used, or the role for the integration of State and Federal designated health care professionals to address surge needs during an emergency. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the findings.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness communication plan was reviewed and updated every two years, creating the increased risk of not addressing the care needs for the patients during the emergency events. Review of the agency's emergency preparedness communication plan was conducted on 1/11/22. The emergency preparedness communication plan failed to show documented evidence the plan was reviewed and updated every two years. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness communication plan included the updated name and contact information of the staff, entities provided services under agreement, patients' physician, and volunteers. This failure had the potential to negatively impact the patients' care needs during the emergency events. Review of the agency's emergency preparedness communication plan was conducted on 1/11/22. The agency's emergency preparedness communication plan showed the agency will utilize the On-Call book and utilize the Pyramid Phone Communication Plan for contacting all home care staff during an emergency; and will be kept up-to-date. However, the agency did not have an On-Call book and the Pyramid Phone Communication plan available for review. In addition, the agency's emergency preparedness plan did not include the addresses, names, and contact information of the staff, entities providing services under agreement, patients' physician, and volunteers. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness communication plan included the contact name and information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. This failure had the potential to negatively impact the patients' care needs during the emergency events. Review of the agency's emergency preparedness policy and plan was conducted on 1/11/22. The agency's emergency preparedness plan did not include the contact information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. On 1/11/22 at 0900 hours, an interview and document review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness communication plan included the information related to the alternate means for communicating with staff, federal, state, regional and local emergency management agencies, creating the risk of not being able to communicate to meet the patient and staff needs during an emergency. Review of the agency's emergency preparedness policy and plan was conducted on 1/11/22. The agency's Emergency Preparedness Policy showed if phones or utilities were interrupted, a designated staff member will contact the repair company informing them of the nature of the service and request priority for restoring service; telephone calls will be forwarded to the answering service or alternate number; staff will utilize pagers, mobile phones, or personal telephones to contact clients to make arrangements for services; and the Director will transfer calls to the answering service and follow procedures for on- call hours. However, the agency's emergency preparedness policy and plan did not include the contact information of the answering service or alternate number used in communicating to Federal, State, tribal, regional, and local emergency management agencies. On 1/11/22 at 0900 hours, LVN 1/ Case Manager was informed and acknowledged the finding.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness plan included the method for sharing information and medical documentation for the HHA's patients with other health providers to maintain the continuity of care, creating the increased risk of not providing appropriate, consistent, and quality care to the patients during the emergency events. Review of the agency's emergency preparedness plan was conducted on 1/11/22. The agency's emergency preparedness communication plan did not include the method for sharing the information and medical documentation for the HHA's patients with other health providers to maintain the continuity of care. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the finding.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This failure created the risk of not providing the necessary care and services to the patients during the emergency events. Review of the agency's P&P and emergency preparedness plan was conducted on 1/11/22. The P&P addressing the emergency preparedness communication plan did not include a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness training and testing program were reviewed and updated every two years, creating the increased risk of not addressing the care needs for the patients during emergency events. Review of the agency's P&Ps titled Emergency Preparedness Policy dated 8/30/19, and Emergency Preparedness Plan dated 10/29/06, was conducted on 1/11/22. The agency's P&Ps did not address the requirement for the emergency preparedness training and testing program should be reviewed and updated every two years. In addition, the agency was unable to provide documented evidence the emergency preparedness training and testing program were in place. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure initial training in the emergency preparedness program was provided to volunteers and contracted individuals providing services under arrangement and documentation of all the emergency preparedness training was maintained. This failure created the risk of the HHA's staff not knowing what to do in case of emergency. Review of the agency's P&Ps titled Emergency Preparedness Policy dated 8/30/19, and Emergency Preparedness Plan dated 10/29/06, was conducted on 1/11/22. The agency's P&Ps did not address the requirement to provide initial emergency preparedness training to the volunteers and contracted individuals. In addition, there was no documented evidence the initial emergency preparedness training was provided to the volunteers and contracted individuals. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the HHA conducted exercises to test the emergency plan at least annually. This failure created the risk of the HHA's staff not knowing what to do in case of emergency. Review of the agency's P&Ps titled Emergency Preparedness Policy dated 8/30/19, and Emergency Preparedness Plan dated 10/29/06, was conducted on 1/11/22. The agency’s P&Ps did not address the requirement for the agency to conduct exercises to test their emergency plan at least annually. In addition, there was no documented evidence the agency had conducted emergency preparedness exercises annually. On 1/11/22 at 0900 hours, an interview and concurrent document review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent Partial Extended Recertification and Emergency Preparedness surveys.Representing the California Department of Public Health: Surveyors 39796, HFEN; 39210, HFEN; and 39539, HFEN.The survey team entered the HHA on 1/4/22 at 0900 hours. The survey team conducted 3 home visits and reviewed 5 active and 2 closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS:ADL: Activities of Daily Living BID: Twice a DayBP: Blood Pressure bpm: beats per minute CHHA: Certified Home Health Aide cm: centimeter(s) DPCS: Director of Patient Service DTI: Deep Tissue Injury F: Fahrenheit gm: gram(s) Hepatitis: inflammation of the liverHS: at bedtime Hyperglycemic: high blood sugar Hypoglygemic: low blood sugar LVN: Licensed Vocational Nursemcg: microgram(s) mg: milligram(s) mg/dl: milligrams(s) per deciliterml: milliliter(s)MSW: Medical Social WorkerOASIS: Outcome and Assessment Information Set P&P: Policy and Procedure PCG: Primary Caregiver PO: By mouthPOC: Plan of CarePRN: As Needed PT: Physical Therapy/TherapistPTA: Physical Therapy AssistantQ: Every QID: Four times a day QD: Daily RN: Registered Nurse Sacrococcyx: Pertaining to both the sacrum and coccyxSacrum: a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis SBP: systolic blood pressure (how much pressure your blood is exerting against your artery walls when the heart beats) SN: Skilled Nursing/NurseSOC: Start of Care Stage 2 pressure injury: partial-thickness loss of skin with exposed dermis; the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister TB: Tuberculosis (an infectious bacterial disease that affects the lungs) Tetanus: a bacterial infection that causes painful muscle spasmsTID: Three Times a Dayu: unit(s)W: Week

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the agency failed to ensure the patients and PCGs were advised of the availability of the state’s contact information for two of seven sampled patients (Patients 4 and 5), creating the risk of violating the patient’s rights to be informed of the process of filing a complaint to the appropriate authorities. 1. Review of Patient 5's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 11/30/21. The patient was certified for home health services during the certification period from 11/30/21 to 1/28/22. On 1/6/22 at 0905 hours, a joint home visit was conducted with the PTA to Patient 5's home. The PCG was asked if she was aware of California Department of Public Health, Licensing and Certification Program contact information. The PCG stated the information was listed in the patient’s admission packet. Review of the admission packet showed the contact information and the toll free hotline number of the California Department of Public Health, Licensing and Certification Program; however, the address for the department was incorrect. On 1/6/22 at 1020 hours, the PTA was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 10/28/21. The patient was certified for home health services during the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/21. On 1/5/22 at 1000 hours, a joint home visit was conducted with LVN 2 to Patient's 6 home. An interview was conducted with the PCG. The PCG was asked if he knew the contact information for California Department of Public Health, Licensing and Certification Program. The PCG showed the contact information was written in the admission packet. Review of the admission packet showed the contact information and toll free hotline number for the California Department of Public Health, Licensing and Certification Program; however, the address for the department was incorrect. On 1/7/22 at 1230 hours, an interview with was conducted with the DPCS. The DPCS was asked for the contact information of the California Department of Public Health, Licensing and Certification Program. The DPCS reviewed the admission packet and stated the address in the admission packet was incorrect and it should be changed. The DPCS was informed and acknowledged the finding.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to implement their P&P addressing the grievances of two nonsampled patients (Patients A and B), creating the risk of violating the patient's rights and not providing quality of care and services to these patients. The agency's P&P titled Grievance Procedure revised 7/10/2010, showed the Coordinator shall conduct an investigation of the complaint. The investigation maybe informal, but it must be thorough. The Coordinator will issue a written decision on the grievance no later than 30 days after its filing. Review of the agency's grievance log showed the following grievances: - A complaint was filed by Patient A's family member on 2/3/20, regarding Patient A's complaints of shortness of breath, low heart rate and open areas on the upper bilateral thighs. The documentation showed the Coordinator provided the instructions to the patient's family member; and the physician notified. However, there was no documented evidence the Coordinator completed a written decision on the grievance as per the agency's P&P. - A complaint was filed by the agency's CHHA on 8/29/19, regarding Patient B being upset related to personal and financial issues. The documentation showed the Coordinator notified the physician and received an order to discharge the patient. However, there was no documented evidence the Coordinator completed a written decision on the grievance as per the agency's P&P. On 1/7/22 at 1020 hours, an interview was conducted with the Administrator and DPCS. They were asked if a written decision of the investigation was sent to the patients. The DPCS stated there was no written decision completed regarding Patients A and B's complaints. On 1/11/22 at 1200 hours, an interview was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the RN conducted the initial assessment visit within 48 hours of the referral for one of seven sampled patients (Patient 7), creating the risk of not identifying and addressing the care needs in a timely manner for this patient. Review of the agency's P&P titled Care Coordination Process dated 2/14/14, showed the initial evaluation is completed by the Registered Nurse within 24 to 48 hours of receiving the referral. Review of Patient 7's clinical record was initiated on 1/4/22. The clinical record showed the referral date was 5/12/20, and the SOC was 5/20/20. The patient was certified for home health services during the certification periods from 9/12/21 to 11/10/21 and 11/11/21 to 1/9/22. Further review of the clinical record showed the initial assessment visit was conducted by the RN on 5/20/20, eight days after the referral date. There was no documented evidence explaining why the initial assessment visit was not conducted within 48 hours of the referral date. On 1/11/22 at 1054 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified the above finding.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the SOC date for four of seven sampled patients (Patients 1, 3, 4, and 5), creating the risk of not identifying and addressing the care needs timely for these patients. Review of the agency's P&P titled Clinical Documentation reviewed 7/19/10, showed the documentation will be completed by the direct caregivers and monitored by the skilled professional responsible for managing the client's care. All documentation is to be completed the day service is rendered. The timely submission of notes include all initial assessments must be seen within 48 hours, documentation (OASIS Assessment) must be turned in within five days of the assessment. 1. Review of Patient 4's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 10/28/21. The patient was certified for home health services during the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/21. a. Review of the initial comprehensive assessment dated 12/22/21, showed the RN had performed the initial comprehensive assessment including neurological/emotional/behavioral status. However, there were no specific goals to address the patients neurological/emotional and behavioral needs. On 1/11/22 at 1125 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager was asked if the goals for the neurological status should be completed. LVN 1/Case Manager stated it was missed and the documentation was incomplete. LVN 1/Case Manager acknowledged the finding. b. Review of the OASIS SOC assessment dated 10/28/21, showed the RN had completed the SOC initial comprehensive assessment including the list of the patient's recent immunizations. However, there was no documented evidence the patient's immunization for tetanus, TB, and hepatitis was assessed. On 1/11/22 at 1153 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager was asked if the patient's immunization status was assessed and should be filled out. LVN 1/Case Manager stated it was missed and the documentation was incomplete. LVN 1/Case Manager acknowledged the finding. 2. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. Review of the initial comprehensive assessment dated 10/14/20, showed the RN performed the initial comprehensive assessment including the patient's vital signs. However, there was no documented evidence the SN assessed the patient's height and weight as part of the initial comprehensive assessment. On 1/11/22 at 1041 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager was asked if the section for the patient's height and weight should be filled out. LVN 1/Case Manager stated the documentation was incomplete. LVN 1/Case Manager acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 11/30/21. The patient was certified for home health services during the certification period from 11/30/21 to 1/28/22. Review of the OASIS SOC assessment dated 11/30/21, showed no documented evidence the health screening was assessed. The form also showed incomplete assessment of Patient 5’s most recent immunizations including Tetanus, TB, TB exposure, and Hepatitis. On 1/11/22 at 1000 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified the above findings. 4. Review of Patient 3's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 10/29/21. The patient was certified for home health service during the certification period from 10/29/21 to 12/27/21. Review of the OASIS SOC assessment dated 10/29/21, showed the religion was important to Patient 6. However, further review of the OASIS SOC failed to show Patient 6's religious preference. On 1/11/22 at 0955 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 verified the above finding.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the agency failed to ensure the medication profiles were updated for three of seven sampled patients (Patients 1, 4, and 5), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. Review of the agency's P&P titled Medication Regimen Review/ Medication Profile revised 3/31/10, showed at the time of admission, and each visit, the Registered Nurse, License Nurse, or Therapist shall reconcile all medications a client may be taking to identify any potential adverse effects and drug interactions, including ineffective drug therapy, significant side effects , significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The Nurse/Therapist shall record on the Medication Profile all prescribed and over the counter medications the client is currently taking. 1. Review of Patient 4's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 10/28/21. The patient was certified for home health services during the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/21. a. Review of the Medication Profile, for the certification period 10/28/21 to 12/26/21, showed the patient's medications included Medihoney (leptospermum honey in hydrocolloidal suspension) apply two to three days until wound closes due to left breast ulcer of the skin; Tylenol (analgesics) 500 mg one tablet PO QD PRN for pain; Anti-diarrheal (antidiarrheal) Oral 2 mg one capsule PO after each loose stool, not to exceed four times a day; pantoprazole sodium (proton pump inhibitor) 40 mg one tablet PO QD; and amlodipine besylate (calcium channel blocker) 5 mg one tablet PO QD. Review of the Patient Communication Form dated 10/28/21, showed a treatment order for the left breast lesion as follows: cleanse with NSS, pat dry, apply a triple antibiotic, cover with a gauze, and secure with tape. However, the Medication Profile did not include triple antibiotic in the medication list. On 1/11/22 at 1130 hours an interview with concurrent clinical record review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding. b. The POC, for the certification period from 12/27/21 to 2/24/21, cited SN visits 2W1 (two visits a week for one week) and 1W8 for body system assessments. The Medication Profile, for the certification period from 12/27/21 to 2/24/22, showed the patient's medications included Anti-diarrheal Oral 2 mg one capsule PO after each loose stool, not to exceed four times a day; pantoprazole sodium 40 mg one tablet PO QD; and amlodipine besylate 5 mg one tablet PO QD. On 1/5/22 at 1000 hours, a joint home visit was conducted with LVN 2 to Patient's 6 home. Review of the patient's medications profile with LVN 2 and the PCG showed the patient was on Tylenol 500 mg one tablet PO every six hours for pain. On 1054 hours, an interview was conducted with the PCG. The PCG was asked as to when was the last time the patient was given Tylenol. The PCG stated, it was given a week ago. However, the Medication Profile did not include Tylenol 500 mg one tablet PO every six hours for pain. A follow-up interview was conducted with LVN 2 . LVN 2 was asked if Tylenol should be included in the medication profile. LVN 2 replied yes and stated she forgot to add it on the medication profile. On 1/11/22 at 1154 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the finding. 2. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. a. The POC, for the certification period from 8/16/20 to 10/14/20, cited SN visits 2W5 and 1W4 for body system assessments. The POC also cited wound assessment and treatment as follows: cleanse the deep tissue injury to the right axilla and right heel with normal saline, gently pat dry, apply skin protectant and open to air; and cleanse the stage 2 pressure injuries to the right axilla and sacrum with NS, pat dry, apply Calmoseptine ointment, and cover with a foam dressing. Review of the Medication Profile, for the certification period 8/16/20 to 10/24/20, showed the medications included Medihoney gel for the pressure injury to the sacrococcyx, left posterior lower leg, and right trochanter; alprazolam (antianxiety) 0.5 mg one tablet PO TID PRN; tramadol (pain medication) 50 mg one tablet PO QID PRN; Silvadene external (topical antimicrobial) 1% apply externally to wound daily; ketoconazole external (topical antifungal) 2% apply externally to feet daily; Symbicort inhalation (bronchodilator) 80-4.5 mcg/act 2 puffs BID PRN; hydrochlorothiazide (diuretics) 25 mg one tablet PO QD; aspirin oral (analgesics) 81 mg one tablet PO QD; Flomax ( benign prostatic hyperplasia) 0.4 mg one capsule PO QD; Banophen (antihistamines) 50 mg one capsule PO QHS; Pepcid (antiacid) 20 mg one tablet PO BID; atorvastatin calcium (anticholesterol) 80 mg one tablet QHS; mirtazapine (antidepressant) 7.5 mg one table PO QHS; and sodium chloride (supply water and salt) 1 gm one tablet PO QD. However, the medication profile did not include Calmoseptine. b. The POC, for the certification period from 10/15/20 to 12/13/20, cited SN visits 2W9 for body system assessments and follow-up wound care treatment for the stage 2 pressure injuries to the sacrococcyx, left middle leg, right hip and right heel. The wound treatment included cleanse with normal saline, pat dry, apply Calmoseptine ointment (skin irritation), and cover with a foam dressing daily until fully healed. Review of the Medication Profile, for the certification period 10/28/20 to 12/26/20, showed the medications included Medihoney gel for the pressure injury to the sacrococcyx, left posterior lower leg, and right trochanter; alprazolam 0.5 mg one tablet PO TID PRN; tramadol 50 mg one tablet PO QID PRN; Silvadene external 1% apply externally to wound daily; ketoconazole external 2% apply externally to feet daily; Symbicort inhalation 80-4.5 mcg/act 2 puffs BID PRN; hydrochlorothiazide 25 mg one tablet PO QD; aspirin oral 81 mg one tablet PO QD; Flomax 0.4 mg one capsule PO QD; Banophen 50 mg one capsule PO QHS; Pepcid 20 mg one tablet PO BID; atorvastatin calcium 80 mg one tablet QHS; mirtazapine 7.5 mg one table PO QHS; and sodium chloride 1 gm one tablet PO QD. However, the medication profile did not include Calmoseptine. On 1/11/22 at 1041 hours an interview with concurrent closed clinical record review was conducted with LVN 1/Case manager. LVN 1/Case Manager was asked if Calmoseptine should be included in the medication profile. LVN 1/Case Manager acknowledged the medication profile was not updated. On 1/11/22 at 0958 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case manager. LVN 1/Case Manager was asked if Calmoseptine should be included in the medication profile. LVN 1/Case Manager acknowledged the medication profile was not updated. 3. Review of Patient 5's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 11/30/21. The patient was certified for home health services during the certification period from 11/30/21 to 1/28/22. The POC, for the certification period from 11/30/21 to 1/28/22, cited SN visits 1W1, 2W2, and 1W6 to assess all the body systems. The Medication Profile showed the patient’s medications included the following: - amiodarone (antiarrhythmic) 200 mg one tablet by mouth daily; - valsartan (antihypertensive) 160 mg half a tablet daily; - Eliquis (anticoagulant) 2.5 mg one tablet by mouth twice a day; - finasteride (used to treat urinary retention) 5 mg one tablet by mouth daily; - tamsulosin 0.4 mg one capsule by mouth at bedtime; - Brilinta (anticoagulant) 90 mg one tablet by mouth every 12 hours; - atorvastatin (used to treat high cholesterol) 80 mg one tablet at bedtime; - colchicine (anti-inflammatory) 0.6 mg one tablet daily as needed for gout; - allopurinol (used to reduce uric acid) 300 mg one tablet by mouth daily; - tramadol 50 mg one tablet by mouth twice a day; - calcium + vitamin D3 and minerals (supplement) 600 mg one tablet by mouth twice a day; and - Tylenol 500 mg one to two tablets by mouth every 6 hours as needed for pain. On 1/6/22 at 0905 hours, a joint home visit was conducted with the PTA to Patient 5's home. Review of the patient’s medications with the PTA and PCG showed the following: -The patient was on metoprolol (used to treat high blood pressure) 100 mg by mouth every day which was not listed in the medication profile. The PCG was unable to recall when the patient started taking the medication; however, PCG stated that the patient had been taking it for a long time. -The patient was on colchine 0.6 mg two tablets by mouth instead of one tablet as needed. -The patient was on aspirin 81 mg by mouth daily as needed for pain which was not listed in the medication profile. On 1/6/22 at 1016 hours, an interview and concurrent clinical record review was conducted with the PTA. The PTA was informed and acknowledged the findings.

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 clinical record review, the agency failed to ensure the physician was informed when the care and services were not provided timely as ordered for three of seven sampled patients (Patients 1, 5, and 7), creating the risk of not providing appropriate, consistent, and quality of care to these patients. 1. Review of Patient 7's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 5/20/20. The patient was certified for home health services during the certification period from 11/11/21 to 1/9/22. Review of the POC, for the certification period from 11/11/21 to 1/9/22, cited PT evaluation and treatment. Review of the PT notes showed Patient 7 was evaluated by the PT on 11/16/21, five days after it was ordered. There was no documented evidence the physician was informed of the delay for PT evaluation. On 1/11/22 at 1040 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified the finding and stated the patient should have been evaluated within 72 hours. 2. Review of Patient 5's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 11/30/21. The patient was certified for home health services during the certification period from 11/30/21 to 1/28/22. The POC, for the certification period from 11/30/21 to 1/28/22, cited PT evaluation during the week of 11/30/21. Review of the Physician Order dated 11/30/21, showed to provide therapy services and for the PT to evaluate and follow-up due to the patient’s chronic lower back pain. Further review of the clinical record showed no documented evidence the patient was evaluated during the week of 11/30/21. There was no documented evidence the physician was informed of no PT evaluation during the week of 11/30/21. On 1/11/22 at 1004 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified the above finding. 3. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. a. The POC, for the certification period from 8/16/20 to 10/14/20, cited PT evaluation and follow up for strengthening, ROM and safety. The documentation showed the PT performed the evaluation on 8/26/20, 10 days after it was ordered. b. The physician order dated 8/27/20, showed to arrange for a podiatry consult due to ingrown toenail. However, the documentation showed the podiatry consult was completed on 9/17/20, 21 days after the order. There were no documented evidence the physician was informed of the delay for PT evaluation and podiatry consult. On 1/11/22 at 0958 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager was asked as to the timeframe for the podiatrist to see the patient. LVN 1/Case manager stated the patient should be seen within 48 to 72 hours of the referral. On 1/11/22 at 1129 hours, during an interview, LVN 1/Case manager was asked as to when the PT should perform the evaluation. LVN 1/Case manager stated the patient should be evaluated within 24 to 72 hours from the date the order. LVN 1/Case manager acknowledged the findings. b. The POC, for the certification period from 10/15/20 to 12/13/20, cited PT evaluation and follow up for mobility and strengthening. However, the documentation showed the PT performed the evaluation on 10/20/20, five days after the physician ordered. There was no documented evidence the physician was informed of the delay for PT evaluation. In addition, the POC also cited SN visits 2W9 for body system assessments and to follow up wound care treatment for the Stage 2 pressure injuries to the sacrococcyx, left middle leg, right hip, and right heel. The wound treatment included to cleanse with NS, pat dry, apply Calmoseptine ointment and cover with foam dressing daily until fully healed. The SN notes showed the SN did not conduct the visits, perform wound assessment and treatment as ordered. Cross reference to G710, example #1.b. However, further review of the clinical record showed no documented evidence the physician was informed of care and services not provided as per the POC. On 1/11/22 at 1041 and 1129 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager was asked as to when the PT should perform the evaluation. LVN 1/Case manager stated the patient should be evaluated within 24 to 72 hours from the date the order. LVN 1/Case manager was asked if the physician was notified of the missed visits. LVN 1/Case manager stated there was no documentation showing the physician was notified of the SN missed visits. LVN 1/Case Manager acknowledged the SN visits should be two times a week.

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, clinical record review, and agency's P&P review, the agency failed to ensure the POCs included pertinent information for two of the seven sampled patients (Patients 4 and 7), creating the risk of not addressing the care needs of these patients. The agency's P&P titled Plan of Care undated, showed the Plan of Care is based on current assessments by the Registered Nurse, Therapists, and other health care team members. The Plan of Treatment or Plan of Care for patients requiring medical orders shall include, but not limited to pertinent information related to medication, treatments, and procedures, food and drug allergies. 1. Review of Patient 4's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 10/28/21. The patient was certified for home health services during the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/21. a. The POC, for the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/21, failed to include the patient's allergies to food and drugs in the individualized plan of care. On 1/11/21 at 1125 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case manager. LVN 1/Case Manager was asked if the POC included an assessment for food and drug allergies. LVN 1/Case Manager stated it was missed and needed to be filled out. LVN 1/Case Manager acknowledged the finding. b. The POC, for the certification period from 10/28/21 to 12/26/21, showed the SN to assess mastitis without abscess and monitor the left breast for worsening signs and symptoms of infection. Review of the SOC initial comprehensive assessment dated 10/28/21, the section of Wound Care Worksheet, showed the patient was assessed to have a wound on the left breast with a date of onset on 10/27/21, measured 4.0 cm (length) x 1.5 cm (width), no drainage and odor, and etiology was infection. Review of the Patient Communication Form dated 10/28/21, showed a wound care treatment for the left breast lesion as follows: cleanse with NSS, pat dry, apply triple antibiotic, cover with a gauze, and secure with tape. However, the POC did not include treatment for the left breast lesion as identified on the initial comprehensive assessment. On 1/11/22 at 1130 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the finding. 2. Review of Patient 7's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 5/20/20. The patient was certified for home health services during the certification period from 9/12/21 to 11/10/21 and 11/11/21 to 1/9/22. The POC dated 9/9/21 and 11/7/21, did not include the patient’s allergies. On 1/11/22 at 1020 hours, LVN 3 verified the above findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview, closed clinical record review, and agency's P&P review, the agency failed to ensure effective coordination of care and services for one of seven sampled patients (Patient 2), creating the risk of not providing necessary care and services to these patients. The agency's P&P titled Care Coordination Process revised 2/14/14, showed the intake nurse or DPCS receives all referrals from all sources, verify eligibility, provide feedback to referral sources, make staff assignments, including contracted services, and will collaborate with the case manager regarding assignments and follow ups. Therapy services and Medical Social Services will complete their initial evaluation within 48 hours post receipt of referral. Review of Patient 2's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 9/7/2019. The patient was certified for home health services during the certification period from 10/31/20 to 12/29/20. Review of Patient 2's Post Hospital Order dated 11/12/20, showed an order for PT for strengthening and mobility. The Physician's Order dated 11/12/20, showed to provide therapy services and follow- up for safety and strengthening. The Case Conference and 60 day Summary dated 11/19/20, showed Patient 2 was transferred to the hospital after a fall; and a plan to refer Patient 2 to PT and MSW for community resources and other patient needs. The Physician's Order dated 11/23/20, showed to arrange for PT evaluation and follow up for strengthening and mobility; and arrange a MSW referral for community resources. However, there was no documented evidence a PT evaluation and/or a MSW assessment were completed for Patient 2 as per the agency's P&P. On 1/11/22 at 1038 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 was informed and acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the agency failed to provide the written instructions on the SN visit schedule for two of seven sampled patients (Patients 4 and 5), creating the risk of not providing the necessary information to these patients. 1. Review of Patient 5's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 11/30/21. The patient was certified for home health services during the certification period from 11/30/21 to 1/28/22. The POC, for the certification period from 11/30/21 to 1/28/22, cited SN visits 1W1, 2W2, and 1W6 to assess all the body systems. The POC also cited PT evaluation during the week of 11/30/21. On 1/6/22 at 0905 hours, a joint home visit with the PTA was conducted to Patient 5's home. The PTA was asked for the written instructions on the SN visit schedule. The PTA stated there was no written instruction on the SN visit schedule provided to the patient. The PTA stated the staff would call the patient or family member the day prior to the visit. The PCG was asked about the schedule of the visits. The PCG verified the HHA staff called the day prior to the home visit and was not provided a visit schedule. Review of the patient's admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 1/6/22 at 1002 hours, an interview and concurrent clinical record review was conducted with the PTA. The PTA was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 10/28/21. The patient was certified for home health services during the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/22. On 1/5/22 at 1000 hours, a joint home visit with the LVN 2 was conducted to Patient's 4 home. An interview with concurrent clinical record review was conducted with LVN 2. LVN 2 was asked if the patient and PCG were provided a written instructions on the SN visit schedule. LVN 2 reviewed the admission packet and acknowledged a written visit schedule was not provided. The PCG was asked if the agency staff provided a written instructions on the SN visit schedule. The PCG replied no, they just called one to two days prior to the visit. On 1/11/22 at 1220 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was informed and acknowledged the finding.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview, clinical record review, and agency's P&P review, the agency failed to ensure the skilled professionals provided care and services in accordance with the POC for three of the seven sampled patients (Patients 1, 3, and 6), creating the risk of not providing appropriate, consistent, and quality care to the patient. 1. Review of the agency's P&P titled Clinical Documentation reviewed 7/19/2020, under the section of Wound Care Documentation, showed all wounds will be assessed with each visit and documentation must include the following: size will be measured upon admission, weekly and PRN, site location, drainage, cleansing, irrigation and or rinsing medium, medication applied and type of dressing. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. a. The POC, for the certification period from 8/16/20 to 10/14/20, cited SN visits 2W5 and 1W4 for body system assessments. The POC showed wound assessment and treatment for multiple pressure injuries. The wounds included a deep tissue injury to the right axilla and right heel with treatment as follows: cleanse with NS. gently pat dry, apply skin protectant and open to air; and Stage 2 pressure injuries to the right axilla and sacrum with treatment as follow: cleanse with NS, pat dry, apply calmoseptine ointment and cover with foam dressing. Review of the SN notes dated, 8/19, 8/25, 8/27, 9/1, 9/3, 9/8, 9/12, 9/17, 9/24, 10/1 and 10/7/20, showed the SN had performed wound treatment and assessment for the Stage 2 pressure injury to the sacral area. Review of the SN note dated 9/19/20, showed the SN had performed the wound treatment for the Stage 2 pressure injury on the sacral area. However, the SN failed to assess the Stage 2 pressure injury to the sacral area as ordered in the POC. On 1/11/22 at 0958 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager was informed and acknowledged the findings. b. The POC, for the certification period from 10/15/20 to 12/13/20, cited SN visits 2W9 for body system assessments and to follow up wound care treatment for the stage 2 pressure injuries to the sacrococcyx, left middle leg, right hip, and right heel. The wound treatment included to cleanse with NS, pat dry, apply Calmoseptine ointment and cover with foam dressing daily until fully healed. - Review of the SN notes dated 10/15,10/20,10/31 and 11/2/20, showed the SN had performed wound assessment and treatment for the stage 2 pressure injury to the sacrococcyx. However, there was no documented evidence the SN performed wound assessment and treatment to the Stage 2 pressure injuries to the right hip, left middle leg, and right heel as ordered in the POC. - Review of the SN notes dated 11/10, 11/17, 11/19, 11/25, 11/30 and 12/7/20, showed the SN had performed wound treatment for the stage 2 pressure injury to the sacrococcyx, left lower lateral leg, right hip, and right heel. However, there was no documented evidence the SN performed wound assessment to the Stage 2 pressure injury to the left middle leg and right heel as ordered in the POC. - Review of the clinical record showed the SN visited the patient to perform body system assessment on the following dates: - Week 2 (10/18 to 10/24), the SN visited the patient on 10/20/20. - Week 3 (10/25 to 10/31), the SN visited the patient on 11/31/20. - Week 4 (11/1 to 11/7), the SN visited the patient on 11/2/20. - Week 7 (11/22 to 11/28), the SN visited the patient on 11/25/20. - Week 8 (11/29 to 12/5), the SN visited the patient on 11/30/20. However, the SN visited the patient once a week instead of two times a week as ordered. On 1/11/22 at 1041 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager was informed and acknowledged the findings. LVN 1/Case manager was asked if the physician was notified of the missed visits. LVN 1/Case manager stated there was no documentation showing the physician was notified of the SN missed visits. LVN 1/Case Manager acknowledged the SN visits should be two times a week. 2. Review of Patient 6's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 11/06/20. The patient was certified for home health services during the certification period from 11/01/21 to 12/30/21. The POC, for the certification period 11/1/21 to 12/30/21, showed to continue to perform skin care to the left heel to prevent recurrence. The SN notes dated 12/15 and 12/30/21, showed the heel was cleansed with normal saline, patted dry, applied skin protectant and cleaned with a gauze, and wrapped with Kerlix. However, there was no documented evidence the physician ordered for wound care provided by the SN on 12/15 and 12/30/21. On 1/11/22 at 1023 hours, an interview and concurrent clinical record review was conducted with the DPCS and LVN 4. The DPCS and LVN 4 was informed and acknowledged the findings. 3. Review of Patient 3's clinical record showed the SOC was 10/29/21. The clinical record showed the patient received home health services during the certification periods from 10/29/21 - 12/27/21 and 12/28/21 to 2/25/22 The POC, for the certification period 12/28/21 to 2/25/22, showed to notify the physician for temperature greater than 101 degrees F or less than 96 degrees F; pulse greater than 100 bpm or less than 60 bpm; respirations greater than 24 or less than 14; systolic blood pressure greater than 160 mmHg or less than 140 mmHg; diastolic blood pressure greater than 90 mmHg or less than 60 mmHg; and oxygen saturation is less than 90%. In addition, the POC cited to perform finger stick for fasting blood sugar during visit, if it has not been done or if patient reported signs and symptoms of hypo/hyperglycemia; and to report to physician if the random blood sugar greater than 400 mg/dl or less than 60 mg/dl. Review of the SN note dated 12/31/21, failed to show documented evidence Patient 3's temperature, pulse, respirations, blood pressure, blood sugar, oxygen saturation level or blood sugar level were assessed and evaluated as cited in the POC. On 1/11/22 at 0955 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 verified the above findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for one of seven sampled patients (Patient 1), creating the increased risk of substandard healthcare outcomes to this patient. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. The POC, for the certification period from 10/15/20 to 12/13/20, cited for PT evaluation and follow up for mobility and strengthening. Review of the physician's order dated 10/20/20, showed the PT reported the frequency for evaluation and treatment as 2W3 and 1W1 for the patient/PCG education/ training, bed mobility, transfer, balance, therapeutic exercises and establish HEP (home exercise program). However, review of the PT Evaluation note dated 10/20/20, showed the frequency of visit as 1W1 and 2W3 On 1/11/22 at 1041 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case manager. LVN 1/Case manager was asked what the PT's frequency of visit was. LVN 1/Case manager stated they should follow the physician's order for PT frequency of visit of 2W3 and 1W1, and acknowledged the PT documented the frequency inaccurately.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the CHHA were provided a written patient care instructions for one of the seven sampled patients (Patient 4), creating the risk of not providing the necessary care to the patients. Review of Patient 4's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 10/28/21. The patient was certified for home health services during the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/21. The POC, for the certification period from 10/28/21 to 12/26/21, cited CHHA visits 1W1 and 2W8 for assistance with ADL/IADL care. However, review of the clinical record failed to show documented evidence a written instruction was provided to the CHHA. On 1/11/22 at 1130 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case Manager was asked if there was a written instruction provided to the CHHA. LVN1/Case Manager further stated it should have been completed. LVN 1/Case Manager reviewed the clinical record and acknowledged the finding.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the CHHA failed to provide services as per the plan of care for three of seven sampled patients (Patients 1, 4, and 7), creating the risk of not providing the appropriate care and services to this patient. 1. Review of Patient 4's clinical record was initiated on 1/6/22. The clinical record showed the SOC was 10/28/21. The patient was certified for home health services during the certification periods from 10/28/21 to 12/26/21 and 12/27/21 to 2/24/21. The POC for the certification period from 10/28/21 to 12/26/21, cited CHHA visits 1W1 and 2W8 for assistance with ADLs/IADL care. Review of the CHHA visit notes dated 10/29, 11/1, and 11/4/2021, showed the CHHA checked the patient's vital signs. However, the POC did not include the instructions for the CHHA to take the patient's vital signs during the CHHA visits. On 1/11/22 at 1130 hours, an interview with concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/ Case Manager was asked if the CHHA should take the patient's vital signs during the CHHA visit. LVN 1/Case manager stated the POC did not provide the instructions for the CHHA to take the patient's vital signs during the CHHA. LVN 1/Case manager was informed and acknowledged the findings. 2. Review of Patient 7's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 5/20/20. The patient was certified for home health services during the certification period from 11/11/21 to 1/9/22. Review of Patient 7’s Aide Care Plan dated 11/11/21, showed to take the patient’s vital signs every CHHA visit. The form also showed to provide assistance with elimination, activity, household, and personal care needs every CHHA visit. Review of the CHHA visit notes dated 11/11, 11/6, 11/18, 11/23, 11/25, 11/30, 12/2, 12/7, and 12/9/21, showed the patient's vital signs were not taken and assistance with elimination, activity, household, and personal care needs were not provided as per the patient's care plan. On 1/11/22 at 1045 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified the above findings. 3. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. a. The POC, for the certification period from 8/16/20 to 10/14/20 , cited CHHA visits 2W9 to assists with ADL care. Review of the CHHA Care Plan dated 8/16/20, showed a written instructions for the CHHA visit. The instruction included to check vital signs every visit, assists with transfer, and turn or positioning the patient. Review of the CHHA notes showed the CHHA visited the patient from Week 1 to Week 3 (8/16 to 9/5/20) and Week 5 to Week 9 ( 9/13 to 10/14/20). However, review of the CHHA note dated 8/20/20, failed to show documented evidence the CHHA checked the patient's vital signs ( BP, pulse, respirations and temperature), transfer and turn or positioning as instructed. The CHHA visit notes dated 8/27/20, failed to show documented evidence the CHHA turned or positioned the patient. In addition, there was no documented evidence of a CHHA visit during Week 4 (9/6 to 9/12/21) as cited on the POC. b. The POC, for the certification period from 10/15/20 to 12/13/20, cited CHHA visits 2W9. Review of the CHHA notes showed from Weeks 2 to 8 (10/18 to 12/5), the CHHA had visited the patients two times a week as cited in the POC. However, during Week 1 (10/15 to 10/17), the CHHA visited the patient one time on 10/15/20, instead of two visits as ordered. On 1/11/21 at 1041 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case Manager. LVN 1/Case manager acknowledged the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the agency's RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for one of seven sampled patients (Patient 3), creating the risk of substandard health outcomes to these patients. Review of Patient 3's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 10/29/21. Patient 3 was certified for home health services during the certification period from 10/29/21 to 12/27/21. The POC, for the certification period from 10/29/21 to 12/27/21, showed CHHA visits 2w2 to start on 10/29/21. Further review of the clinical record showed no documented evidence the agency's RN had conducted the CHHA supervisory visit no less frequently than every 14 days during this certification period until 12/27/21. The Recertification OASIS assessment dated 12/27/21, showed the RN completed a supervisory visit. On 1/11/22 at 0955 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 was informed and acknowledged the finding.

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 document review, the agency failed to ensure the written agreement with the contracted social services company (Company 1) included the role of the contracted company in discharge planning. This created the risk for not providing necessary services related to discharge planning for the patient. According to Title 22, Division 5, Chapter 6, Article 4, 74719 Services Arranged by Agreement, when a service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include the role, if any, of the agency and the contracted individual or agency in the patient discharge planning process. Review of the written agreement between the agency and Company 1 providing social services was conducted on 1/7/22. The written agreement with Company 1 dated 6/5/20, did not include the role of agency and Company 1 in patient discharge planning process. On 1/11/22 at 1128 hours, LVN 4 was informed and acknowledged the finding.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview, clinical record review, and agency P&P review, the agency failed to ensure the discharge/transfer summary for two of seven sampled patients (Patients 1 and 2) were completed. This deficient practice created the risk of risk of substandard care provided to these patients as their clinical information were not accurate and complete. Review of the agency's P&P titled Discharge Transfer/ Referral Criteria (undated), showed the nurse will confirm the transfer arrangements, including completing the transfer summary report and place a copy of the transfer summary report into the patient's clinical record. Review of the agency's P&P titled Care Coordination Process revised date 2/14/14, showed the patient is prepared for discharge during the last two visits unless services are abruptly terminated (of which the Discharge Summary should reflect reason). 1. Review of Patient 2's closed clinical record was initiated on 1/4/22. The closed clinical record showed the SOC was 9/6/19. The patient was certified for home health services during the certification period from 10/31/20 to 12/29/20. Review of Patient 2's physicians' orders dated 11/23/20, showed Patient 2 was admitted to the hospital on 11/20/20 and was discharged on 11/22/20. Review of Patient 2's physician's order dated 11/27/20, showed Patient 2 was transferred to a general acute care hospital and discharged from home health services. Further review of Patient 2's closed clinical record failed to show documented evidence the transfer summary report was completed after the transfer on 11/27/20, to a general acute care hospital. In addition, there was no documented evidence a discharge summary report was completed. On 1/11/22 at 1038 hours, an interview and concurrent clinical record review was conducted with the DPCS and LVN 4. The DPCS was informed and acknowledged the findings. 2. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. The POC, for the certification period from 10/15/20 to 12/13/20, cited SN visits 2W9 for body system assessment and to provide wound care treatment to the stage 2 pressure injuries to the sacrococcyx, left middle leg, right hip, and right heel. The POC also cited CHHA visits 2W9 to assist in ADL care and PT evaluation and follow up for mobility and strengthening. The Discharge OASIS dated 12/8/20, showed wound assessment of the stage 2 pressure injury to the sacrococcyx. However, there were no assessments of the stage 2 pressure injuries to the left middle leg, right hip and right heel. In addition, the Discharge Summary dated 12/8/20, did not include the frequency of each services and treatment provided by the agency. On 1/11/22 at 1119 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case manager. LVN 1/Case Manager was informed and acknowledged the findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview, clinical record review, and agency P&P review, the agency failed to ensure the clinical record was completed in a timely manner for two of seven sampled patients (Patients 1 and 7), creating the risk of not appropriately authenticating the contents of the patient's clinical record. Review of the agency's P&P titled Physician Orders revised on 7/8/09, showed drugs and treatments a re administered by the agency staff only as ordered by the attending physician. Such order may be given by telephone and shall be signed by the patient's attending physician, dentist, podiatrist or other licensed and legally authorized practitioner within his/her scope of practice within 30 working days. 1. Review of Patient 7's clinical record was initiated on 1/4/22. The clinical record showed the SOC was 5/20/20. The patient was certified for home health services during the certification period from 9/12/21 to 11/10/21. - Review of the POC for the certification period of 9/12/21 to 11/10/21, showed the document was signed by the physician on 12/29/21, more than 30 working days after it was developed. - Review of the POC for the certification period of 11/11/21 to 1/9/22, showed no documented evidence of the physician's signature. - The CHHA noted showed the CHHA conducted the visits on 12/16, 12/21, 12/23, and 12/30/21. However, there was no documentation on what care and services was provided by the CHHA during these visits. On 1/11/21 at 1034 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified the above findings. On 1/11/22 at 1009 and 1020 hours, an interview and concurrent clinical record review was conducted with LVN 3. LVN 3 verified the finding and stated it should be signed within 30 days. 2. Review of Patient 1's closed clinical record was initiated on 1/4/22. The clinical record showed the SOC was 8/16/20. The patient was certified for home health services during the certification periods from 8/16/20 to 10/14/20 and 10/15/20 to 12/13/20. The POC, for the certification period from 8/16/20 to 10/14/20, showed the RN electronically signed and dated the POC on 8/16/20. However, the physician signed and dated the POC on 11/6/20, more than 30 working days from the verbal order. On 1/11/22 at 0958 hours, an interview with concurrent closed clinical record review was conducted with LVN 1/Case manager. LVN 1/Case manager was informed and acknowledged the finding.