Every finding on record at Victory Home Health Agency

The following reflects the findings of the California Department of Public Health during a Re-Certification Survey conducted from August 14, 2023, through August 17, 2023. Representing the California Department of Public Health: Surveyor: 29623, HFEN; Surveyor: 41459, HFEN; and Surveyor: 44173, HFEN. The agency's current active census: 14 The agency's unduplicated admissions during the past 12 months: 39 Sample Size: 7 Record review with Home Visits: 3 Record review without Home Visits: 2 Closed Record reviewed: 2

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patient's initial Comprehensive Adult Nursing Assessment and Recertification Follow-Up Assessments were complete and accurate for five of seven patients reviewed (Patients 1, 2, 5, 6, and 7). This failure had the potential to interfere with Patient's 1, 2, 5, 6, and 7 abilities to participate in their own care, the development of specific Plan of Care (POC), the provisions of the necessary care and services and may delay their recovery towards discharge. Findings: 1. During a review of Patient 1's record on August 14, 2023, the record indicated Patient 1 was admitted to the agency with the Start of Care (SOC) date of July 13, 2023, with diagnoses which included hypertension (high blood pressure). The initial Comprehensive Adult Nursing Assessment for the certification period from July 13, 2023 to September 10, 2023, indicated the following; - The Patient's Representative section was missing the responsible party's (RP) vital information. There were no RP's name and title, telephone numbers, and address; and - The Current DME (Durable Medical Equipment) / Medical Supplies section was missing the DME's company's name, and telephone number. 2. During a review of Patient 2's record on August 14, 2023, the record indicated Patient 2 was admitted to the agency with the Start of Care (SOC) date of April 28, 2023, with diagnoses which included malignant neoplasm of the left breast (cancer of the left breast). The initial comprehensive assessment for the certification period from April 28, 2023 to June 26, 2023, indicated the following: - The Advance Directives was blank; - The Living Arrangements/Supportive Assistance information about the Primary Caregiver (PCG) had no telephone number and address; - The psychosocial assessment was incomplete. The assessment did not include Patient 2's spiritual resource, sleep frequency, MSW (Medical Social Worker) referral...and how the psychosocial condition affects functional ability; and - The current DME/Medical Supplies section was blank. The Recertification / Follow-Up Assessments for the certification period from June 27, 2023 to August 25, 2023, indicated the following; - The Advance Directives and ADL (Activity of Daily Living) were blanks; - The Patient History and Diagnoses section was blank; - The Living Arrangements / Supportive Assistance information about the PCG had no telephone number and address; - The Vital Signs which included the temperature, pulse rate, respirations and blood pressure was blank; - The psychosocial assessment was incomplete. The assessment did not include Patient 2's spiritual resource, sleep frequency, MSW referral... and how the psychosocial condition affect functional ability; - The Functional Abilities and Goals, Activities permitted, Therapy Needed and Plan of Care, Risk Factors/Hospital Admissions/Emergency Room, and Patient/Caregiver/Representative/Family Education and Training were blanks; - The Recertification Summary did not contain the summary of setbacks/Improvements since prior assessment; - The Rehabilitation Potential/Anticipated Discharge For Plan Of Care did not include if discharge plan was discussed with the patient or Representative; and - The Current DME/ Medical Supplies was blank. 3. During a review of Patient 5's record on August 14, 2023, the record indicated Patient 5 was admitted to the agency with the Start of Care (SOC) date of May 31, 2023, with diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental status). The Initial comprehensive assessment at the SOC for the certification period from May 31, 2023 to July 29, 2023, indicated the following; - Patient History and Diagnoses did not include physician's information of patient's last visit and contact, primary reason for home health admission and certifying physician's prognosis; - Height and weight was blank; and - Living arrangements/Supportive Assistance. Primary Caregivers Information was missing. Patient 5 was living in a Residential Care Facility for Elderly (RCFE). No information of the RCFE's name, owner's name and contact information; The Recertification/ Follow-Up Assessment for the certification period from July 30, 2023 to September 27, 2023, indicated the following: - The Emergency contact/Representative contact information did not include representative's address; - Patient History and Diagnoses, Endocrine / Hematology, Food/Environmental Allergies, Mental Status, Musculoskeletal was incomplete, Strengths, limitations, Risk Factors/Hospital Admission/Emergency Room information were blanks; - The Recertification Summary did not include summary of setbacks/improvements since prior assessment; - The Rehabilitation Potential/Anticipated Discharge For Plan of Care did not include discussion of discharge plan with Patient 5's representative, restorative potential and anticipated discharge status; and - The current DME/ Medical Supplies Patient 5 was currently using was not documented. 4. During a review of Patient 6's record, on August 14, 2023, the record indicated Patient 6 was admitted to the agency with the Start of Care (SOC) date of June 12, 2023, with diagnoses which included hypertension (high blood pressure) and dementia (memory loss). The Comprehensive Adult Nursing Assessment at the SOC for the certification period from June 12, 2023 to August 10, 2023, indicated the following: - The Patient's Representative information was blank; and - The Patient History and Diagnoses did not include the physician's last visit and contact, and the certifying physician's prognosis. 5.During a review of Patient 7's record on August 14, 2023, the record indicated Patient 7 was admitted to the agency with the Start of Care (SOC) date of August 22, 2023, with diagnoses which included malignant neoplasm of the brain (brain cancer). The Comprehensive Adult Nursing Assessment at the SOC for the certification period from August 22, 2023 to October 20, 2023, indicated the following: - The Physician's information was not written; - The Patient Representative information was left blank; - The Patient History and Diagnoses did not include the date Patient 7 was last seen by the physician, the certifying physician's prognosis; - The Advance Directives section was blank; - The Living Arrangements/Supportive Assistance Primary Caregiver's information was not written; - Incomplete Pain Assessment; and - The Functional Limitations, current DME / Medical Supplies, Emergency Preparedness Care Planning, and Risk Factor's /Hospital Admission/Emergency Room information were blanks. During a home visit on August 15, 2023, at 9:05 a.m., conducted with the Licensed Vocational Nurse (LVN) 1, for Patient 5, indicated Patient 5 was residing in a Residential Care Facility for Elderly (RCFE). Resident 5 was observed sitting on the sofa, with two caregivers (CG) present. Patient 5 was making sounds, not able to verbalize her needs. Patient 5 needed one to two persons assistance to repositioned her on the sofa. During concurrent interview and review of Patient 5's RCFE folder, at 9:20 a.m., with Patient 5's caregiver (CG) the patient's folder indicated Patient 5's Responsible Party (RP) was a family member. The RCFE had the RP contact information but was not documented in the agency's patient information. The RCFE's CG stated Patient 5's FM lives far away, and visits at least once a month. During an interview with Patient 5's RP, on August 15, 2023, at 5:20 p.m., the FM stated Patient 5 had no Advance Directives (AD). The FM agreed for the agency to assist her in formulating the AD. The FM stated Patient 5 will remain at the RCFE. During a concurrent interview and record review on August 15, 2023, at 3:20 p.m., with the Director of Patient Care Services (DPCS)/Administrator (Admin), the Adult Comprehensive Assessments and the Recertification Follow-Up Assessment for Patients 5, 6, and 7 were reviewed. The ADPCS/Admin acknowledged the initial Adult Comprehensive Assessment and Recertification Follow-Up Assessment for Patients 5, 6, and 7 were missing vital information required during the SOC, and during the recertification period. She stated the RN who conducted the assessments should have obtained the necessary information from the patient or patient's representatives upon the SOC. She stated she should have checked the RN's completions of the initial comprehensive assessments and the recertification assessments. During a concurrent interview and record review on August 16, 2023, at 11:30 p.m., with the Director of Patient Care Services (DPCS)/Administrator (Admin), Patient 1 and 2's Adult Comprehensive Assessments and the Recertification Follow-Up Assessment for Patient 2 was reviewed. The ADPCS/Admin acknowledged the initial Adult Comprehensive Assessment and Recertification Follow-Up Assessment for Patient 1 and Patient 2 were missing vital information required during the SOC, and during the recertification period. The DPCS/Admin stated the RNs should be aware that all information in the assessments should be obtained at the time of Start of Care. If the patient can't assist with the information than the RN should retrieve the information from the patient's representative. The DPCS/Admin stated she needs to review the RN's completed assessments to make sure all the information is present. During a record review of the facility's policy and procedure (P&P) titled, "Initial Assessments/Comprehensive Assessments," dated January 2020, the P&P indicated, "Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient's current health status and include information to demonstrate the patient's progress toward achievements of desired outcomes... relevant diagnoses and current health status, including all active health and medical problems. Relevant medical history, Prognosis, and Physical assessment /review of systems and pertinent physical findings...psychosocial status, functional and cognitive status, assessment of patient's psychosocial status and his/her functional capacity within the community is intended to be a screening of the patients relationships, living environment, impact on the delivery of services and ability to participate in his/her own care...assessments of a patients cognitive status refers to an evaluation of the degree of his/her ability to understand, remember and participate in developing and implementing the plan of care.

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 that a medication listed in the patients Plan of Care (POC) and current medication profile were updated, accurate, and complete for one of three patients reviewed (Patient 2) when the medication Levothyroxine Sodium (used to treat hypothyroidism, a condition when your thyroid gland produces too little thyroid hormone) dosage on Patient 2's prescription bottle was 88 micrograms (a unit of measurement) one table daily and the agency's medication profile (MP a current list of all medications prescribed for a specific patient) indicated Levothyroxine Sodium dosage as 75mcg one tablet daily. This failure had the potential for Patient 2, and her primary caregiver (PCG) not to be able to identify the significant drug interactions, ineffective drug therapy, and non-compliance with prescribed medications. Findings: During a review of Patient 2's record on August 14, 2023, the record indicated, Patient 2 was admitted to the agency with the Start of Care (SOC) date of April 28, 2023, with diagnoses which included Malignant Neoplasm of Left Breast (cancerous tumor to left breast) and Essential Hypertension (occurs when you have abnormally high blood pressure). The POC for the certification period 4/28/23 through 6/26/23, indicated "SN to assess environment for medication compliance and management...caregiver and patient will be able to verbalize understanding of disease process, medications and adverse effects..." During a home visit on August 15, 2023, at 10:23 a.m., conducted with Registered Nurse (RN) 1 for Patient 2, indicated Patient 2 opened the door. Patient 2 was observed holding on to the sides of the wall until she ambulated back to her wheelchair. Patient 2 was alert, oriented, and able to verbalize her needs. Patient 2 was aware of the visit and signed the consent for home visit. Patient 2 stated she lives alone but does have a caregiver that comes to assist her with activities about eight hours a day. Together they manage her medications. A concurrent interview and medication review was conducted on August 15, 2023, at 10:40 a.m., with Patient 2 and RN 1. Patient 2's prescription bottle indicated Levothyroxine Sodium 88 mcg, one tablet by mouth daily for Hypothyroidism. The agency's current "Medication Profile" dated June 24, 2023, indicated, Levothyroxine 75 mcg one tablet by mouth daily for Hypothyroidism. The physician order dated July 27, 2023, indicated Levothyroxine Sodium as 88mcg one tablet by mouth daily for Hypothyroidism. During an interview on August 15, 2023, at 10:45 a.m., with RN 1, RN 1 stated she has been reconciling the medications every visit, she continued to state, "I don't know what happened." During an interview on August 16, 2023, at 11:00 a.m., with the Director of Patient Care Services (DPCS), The DPCS stated, "All the medications should be reviewed every nursing visit." During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation," dated March 2018, the P&P indicated "...the agency will reconcile patient's medications at time of admission and on an ongoing basis 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...medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated...

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient's vaccination screening for influenza (flu) and pneumonia (lung infection) was implemented by the Registered Nurse (RN) during the initial comprehensive assessment at the Start of Care (SOC) and during each recertification assessments for five of seven patients reviewed (Patients 1, 2, 5, 6, and 7). This failure had the potential for Patients 1, 2, 5, 6, and 7, not to receive the vaccinations timely, as needed to protect them from viral infection when the agency can offer the administration of the vaccines per policy and procedure. In addition, this failure may put the highly vulnerable patients at risks to develop signs and symptoms of respiratory infection. Findings: 1.During a review of Patient 1's record on August 14, 2023, the record indicated Patient 1 was admitted to the agency with the Start of Care (SOC) date of July 13, 2023, with diagnoses which included hypertension (high blood pressure). The immunizations section under Patient History and Diagnoses of the initial Comprehensive Adult Assessment, dated July 13, 2023, for the certification period from July 13, 2023 to September 10, 2023, was reviewed. The pneumonia was checked indicating Patient 1 had pneumonia vaccine, but the date of immunization was not written. The Influenza was not marked in the assessment. 2. During a review of Patient 2's record on August 14, 2023, the record indicated Patient 2 was admitted to the agency with the Start of Care (SOC) date of April 28, 2023, with diagnoses which included malignant neoplasm of the left breast (cancer of the left breast). The immunizations section under Patient History and Diagnoses of the initial Comprehensive Adult Assessment, dated April 28, 2023, for the certification period from April 28, 2023 to June 26, 2023, was reviewed. The immunizations section was left blank. The Recertification Follow-Up Assessment dated June 24, 2023, for the certification period from June 27, 2023, to August 25, 2023, was reviewed. The immunization section was left blank. Patient 2 was not screened for the administration of vaccines. 3. During a record review of Patient 5's record, on August 14, 2023, the record indicated Patient 5 was admitted to the agency with the Start of Care (SOC) date of May 31, 2023, with diagnoses which included Alzheimer's disease (a progressive disease that destroys the memory and other important mental status). The immunizations section under Patient History and Diagnoses of the Comprehensive Adult Nursing Assessment dated May 31, 2023, was reviewed. The immunizations section was left blank. The Recertification Follow-Up Assessment dated July 29, 2023, for the certification period from July 30, 2023 to September 27, 2023, was reviewed. The immunization section indicated the influenza immunization was checked but the date of administration was not completed. The pneumonia and other vaccines were not completed. 4. During a record review of Patient 6's record, on August 14, 2023, the record indicated Patient 6 was admitted to the agency with the Start of Care (SOC) date of June 12, 2023, with diagnoses which included hypertension (high blood pressure) and dementia (memory loss). The immunizations section under the Patient History and Diagnoses of the Comprehensive Adult Nursing Assessment, dated June 12, 2023, was reviewed. The immunization section was blank. The immunizations section of the Recertification Assessment dated August 8, 2023, was reviewed. The immunizations/screening section indicated the influenza and pneumonia vaccines were checked. There were no dates of the immunizations. 5. During a record review of Patient 7's record, on August 14, 2023, the record indicated Patient 7 was admitted to the agency with the Start of Care (SOC) date of August 22, 2022, with diagnoses which included malignant neoplasm of the brain (brain cancer). The immunizations section under Patient History and Diagnoses of the Comprehensive Adult Nursing Assessment, dated August 22, 2022, was reviewed. The immunization section indicated the pneumonia vaccine was checked without the date of immunization. The influenza was not marked. During a concurrent interview and record review on August 15, 2023, at 3:30 p.m., with the DPCS/Administrator for Patients 1, 2, 5, 6, and 7 immunizations assessments, the DPCS/Administrator acknowledged the immunizations section of the Comprehensive Assessments and Recertification Assessments were not completed accurately. She stated the Registered Nurse who conducted the initial and recertification assessments should have screened and completed the immunizations history. She further stated she should have reviewed the immunizations history of all their patients. A review of the agency's policy and procedure titled, "Influenza Vaccination Program," dated March 2018, indicated, "...Agency may administer influenza and pneumococcal vaccines only after consultation with patient's physician, obtaining a physician's order and assessing the patient for contraindication...Improve patient outcomes by decreasing transmission of influenza..." A review of the agency's policy and procedure titled, "Vaccinations," dated 03/2021, indicated, "...The agency will comply with CMS regulation & the CDC's Advisory Commitee on Immunization Practices for influenza and pneumococcal pneumonia vaccination for patients over the age 65 years...Influenza and pneumococcal vaccines may be administered per agency's policy...after an assessment of the patient to determine for the screening contraindications..."

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure physician's verbal orders were signed and dated timely, within 30 days of the order date, for four of seven patients reviewed (Patients 1, 2, 5, and 6). This failure resulted in verbal orders not being authenticated and dated by the physicians in accordance with the agency's policy and procedure. This failure also had the potential to result in incorrect verbally ordered medications, and treatments for patients which could cause unnecessary care and services. Findings: 3. During record review of Patient 5's record, on August 14, 2023, the record indicated Patient 5 was admitted to the agency with the Start of Care SOC) date of May 31, 2023, with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental status). The Plan of Care (POC) dated May 31, 2023, signed by the Registered Nurse for the certification period from May 31, 2023 to July 29, 2023, indicated the POC was not signed by the attending physician since the SOC. 4. During record review of Patient 6's record, on August 14, 2023, the record indicated Patient 6 was admitted to the agency with the Start of Care (SOC) date of June 12, 2023, with diagnoses which included hypertension (high blood pressure) and dementia (memory loss). The following orders were not signed by the physician: - The admission verbal order to admit Patient 6 to the agency; - The physician's Certification of Face-To-Face Encounter for the certification period from June 12, 2023 to August 10, 2023; and - The Plan of Care (POC) dated June 12, 2023, signed by the Registered Nurse (RN) for the certification period from June 12, 2023 to August 10, 2023. During a concurrent interview and record review on August 15, 2023, at 3:10 p.m., conducted with the Administrator and the Office Manager, the physician's admission orders, POC, and the Physician's Certification Face-To-Face Encounter documents were reviewed. The Administrator stated the physician for Patient 6, should have signed those documents within 30 days of the order dates. She stated the agency was not able to follow up on obtaining the physician's signature timely. During a review of the agency's policy and procedure titled, "Physician's Orders- Verbal Orders," dated March 2018, indicated, "...Verbal orders are put in writing and signed and dated by the RN...Orders are obtained prior to the provision of any care...All verbal orders must be subsequently signed by the physician (within 30 days...)". During a record review of Patient 1's record, on August 14, 2023, the record indicated Patient 1 was admitted to the agency with a Start of Care (SOC) date of July 13, 2023, with a diagnosis of Essential Hypertension (high blood pressure that is not due to another medical condition). -The Physician Certification of Face-to-Face Encounter for the certification period of July 13, 2023, through June 10, 2023, were not signed or dated by the physician. -The Comprehensive Assessment for July 13, 2023 through September 10, 2023, was not signed by the physician. 2. During a record review of Patient 2's record, on August 14, 2023, the record indicated Patient 2 was admitted to the agency with a Start of Care (SOC) date of April 28, 2023, with a diagnosis of Malignant Neoplasm and Essential Hypertension. -The Physician Certification of Face-to-Face Encounter for the certification period of April 28, 2023, through June 26, 2023, were not signed or dated by the physician. -The Plan of Care (POC) dated April j28, 2023, signed by the Registered Nurse for the certification period from April 28, 2023, through June 26, 2023, indicated the POC was not signed by the primary care physician since the SOC. -The Plan of Care (POC) dated June 24, 2023, signed by the Registered Nurse for the certification period from June 27, 2023, through August 25, 2023, indicated the POC was not signed by the primary care physician since recertification visit on June 24, 2023. -The Physician Order dated April 28, 2023, for the certification period of April 28, 2023, through June 26, 2023, indicated the physician order was not signed or dated by the primary care physician since SOC on April 28, 2023. -The Physician Order dated May 17, 2023, for the certification period of April 28, 2023, through June 26, 2023, indicated the physician order was not signed or dated by the primary care physician since SOC on April 28, 2023. -The Physician Order dated July 13, 2023, for certification period of June 27, 2023, through August 25, 2023, indicated the physician order was not signed or dated by the primary care physician since recertification period visit on June 24, 2023.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to follow infection control precautions for one of three patients (Patient 2) when the Registered Nurse did not place a clean barrier (a device used to limit potentially infectious contact between health care providers and patient's) before putting down her nursing bag on Patient 2's furniture. This failure had the potential for patients to suffer inferior care practices risking transmission of infectious agents through cross contamination. Findings: During a review of Patient 2's record on August 14, 2023, Patient 2's record indicated, Patient 2 was admitted to the agency with the Start of Care (SOC) date of April 28, 2023, with diagnoses which included Malignant Neoplasm of Left Breast (cancerous tumor to left breast) and Essential Hypertension (occurs when you have abnormally high blood pressure). The POC for the certification period April 28, 2023 through June 26, 2023, indicated "SN to assess for signs and symptoms of infection, SN to instruct and educate the patient and caregiver on infection control measures." During an interview on August 15, 2023, at 10:30 a.m., with Registered Nurse (RN 1). RN 1 stated, "I guess I should put something like a barrier under my bag." During an interview on August 16, 2023, at 11:10 a.m., with the Director of Patient Care Services (DPCS). The DPCS stated all the nursing staff should know they need to place a barrier between any nursing supplies and patient belongings. A review of the facilities policy and procedure (P&P) titled, "Bag Technique," dated January 2023, the P&P indicated, "...the bag will be placed on a clean dry surface (i.e., a surface that can easily disinfected) in the car and in the home..."

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 observation, interview, and record review the home health agency failed to ensure that the Home Health Aide (HHA) visit note followed the HHA Care Plan prepared by the Registered Nurse for two of three patients. (Patient 1 and 6). This failure had the potential to result in harm to Patient 1 due to lack of care from the home health aide and the plan of care not being individualized to Patient 1 and 6's needs. Findings: During a record review of the Home Health Aide Care Plan (HHA Care Plan), on August 14, 2023, prepared by the Registered Nurse, indicated the nursing staff caring for Patient 1 and 6 were given assignments placed in categories (Patient Specific Information, Goals, Personal Care, Activity, Elimination, Home Management, Nutrition, and Private Cases Only). Certain tasks were to be performed every Home Health Aide visit. The Home Health Aide Weekly Visit Timesheet did not have an area for the Home Health Aide to document Patient Specific Information or Goals. Many of the other categories from the Home Health Aide Care Plan did not coincide with the Home Health Aide Weekly Visit Timesheets. 1. During a review of Patient 1's record, on August 14, 2023, the record indicated Patient 1 was admitted to the agency with the Start of Care (SOC) date of July 13, 2023, with a certification period of July 13, 2023, through September 10, 2023. Patient 1' s diagnosis included Essential Hypertension (occurs when you have abnormally high blood pressure). During a record review of Patient 1's record, on August 14, 2023, the record indicated the Home Health Aide Visits were scheduled two times a week for eight weeks (2wk8), the Home Health Aide Weekly Visit Timesheets dated July 14, 2023, through August 12, 2023, were reviewed. The Home Health Aide Care Plan did not coincide with the Home Health Aide Weekly Visit Timesheets. 2. During a review of Patient 6's record, on August 14, 2023, the record indicated Patient 6 was admitted to the agency with the Start of Care (SOC) date of June 12, 2023, with diagnoses which included hypertension (high blood pressure) and dementia (memory loss). The Home Health Aide visits were scheduled for two times a week for eight weeks (2wk8), the Home Health Aide Weekly Visit Timesheets dated June 12, 2023, through August 10, 2023, were reviewed. The Home Health Aide Care Plan did not coincide with the Home Health Aide Weekly Visit Timesheets. During an interview on August 15, 2023, at 7:30 a.m., with Home Health Aide (HHA)1, she stated the RN fills out the Home Health Aide Care Plan sheet and she follows it. During an interview on August 16, 2023, at 11:20 a.m., with the Administrator/Director of Patient Care Services, she agreed that the Home Health Aide Weekly Visit Timesheets for Patient 1 and Patient 6 should coincide with the Home Health Aide Care Plan. A review of the facility's policy and procedure (P&P) titled, "Home Health Aide Plan of Care," revised April 2015, indicated "...each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide...the patient's Case Manager, upon initialization of aide services, will develop the home health aide plan of care, consistent with the comprehensive plan of care and physician orders...the home health aide plan of care will be reviewed with the patient to ensure understanding of the aides role in the home..."