Every finding on record at Virginia Home Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44911, Health Facilities Evaluator Nurse Surveyor # 44749, Health Facilities Evaluator Nurse Unduplicated Admissions - 120 Active Patients - 32 Sample Size – 7 Patients Home Visits – 3

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide written notice of the patient’s rights within four days after the patient moved from one location to another for one of seven (Patient 1) sampled patients. This deficient practice has the potential to violate the patient's rights to have an understanding and knowledge of the services provided by the HHA. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 4/27/2022, with a primary diagnosis of essential primary hypertension (HTN, high blood pressure that has multiple factors and does not have one distinct cause), and diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic chronic kidney disease (a type of kidney disease present over time caused by diabetes). A review of Patient 1’s Plan of Care (POC) for certification period from 10/24/2022 to 12/22/2022 indicated Skilled Nurse (SN) to visit once a week for nine weeks, Physical Therapy (PT) once a week for seven weeks, and certified home health aide (CHHA) to visit twice a week for nine weeks. On 12/15/2022 at 10:02 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 2 at Patient 1’s home residence. Patient 1 was resting in bed watching television. Patient 1’s daughter/patient care giver (PCG) was in the home during the home visit. During an interview on 12/15/2022 at 10:07 AM, with LVN 2 stated, Patient 1 moved to her daughter’s home about a month ago. LVN 2 stated Patient 1’s HHA admission folder was not currently in the present home but still at the patient’s previous location. During an interview on 12/15/2022, at 10:09 AM, with Patient 1’s daughter/PCG, PCG stated she does not have the patient’s admission folder, PCG stated the HHA admission folder was left at the patient’s previous home location. During an interview on 12/15/2022, at 10:26 AM, with LVN 2 stated, Patient 1 should have brought the HHA admission packet from the patient’s previous home or the HHA should have provided a new HHA admission folder containing all the necessary information including a copy of the patient’s rights for the patient’s new home residence. LVN 2 stated this was important, so the patient knows their rights, has a copy of their Medication Profile listing their current medications, information regarding where to file a complaint with the Department of Public Health, and so the patient has the instructions regarding the services the HHA is supposed to provide. During an interview on 12/16/2022, at 10:09 AM, with the Director of Patient Care Services (DPCS), DPCS stated the HHA admission folder contains copies of consents for treatments, explanation of services the HHA will provide such as SN visits, CHHA visits, PT visits as well as a list of the patient’s current medications. DPCS stated when Patient 1 moved from one location to another, the HHA admission folder should go with the patient. DPCS stated if the HHA admission folder does not come with the patient from one location to another, the HHA must provide the patient with a new admission folder immediately. A review of the HHA’s policy and procedure (P&P) titled, “Patient’s Rights Documents”, revised 8/22/2016, indicated the agency will maintain verification that the patient received a copy of the Patient Rights. The P&P indicated the purpose is to assure that the patient is aware of his/her rights and responsibilities. The P&P indicated the primary service performing the initial assessment will place the patient’s copy of the Patient Rights form in the home folder.

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 home health agency (HHA) failed to maintain an updated medication profile for three of seven sampled patients (Patient 1, 4, and 5). a. For Patient 1, the HHA failed to update the Medication Profile and identify incorrect concentration for Synthroid (levothyroxine) medication. b. For Patient 4, the HHA failed to update the Medication Profile with new and discontinued medications. c. For Patient 5, the HHA failed to update the Medication Profile with new and discontinued medications. This deficient practice placed these patients at greater risk for medication errors and adverse drug reactions. b. A review of Patient 4's face sheet indicated he was admitted to the HHA agency on 10-5-22, with an admitting diagnosis of essential primary hypertension (abnormally high blood pressure) and hyperlipidemia (abnormally elevated levels of lipids in the blood). A review of Patient 4’s plan of care indicated skilled nurse visits once per week and physical therapy visits of 1x/week On 12-15-22, at 10 am, during a home visit, the medication profile for pt4 was not current and updated. The following medications were not indicated in the current med profile and was not. Hydroclorothiazide 25mg PO 1 tab daily Meloxican 15 mg PO 1 tab daily Levothyroxine 25mg 1 tab PO daily Amlodipine Besylate 10 mg 1 tab PO daily Telmisartan 80 mg 1 tab PO daily The following medications for PT4 should have been removed from the current medication profile due to being discontinued. Meclizine HCL Oral 25mg 1 tab TID prn dizziness Ferrous Sulfate Oral 325mg 1 tab daily Hydralazine HCl Oral 500mg 1 tab twice daily Stool softener Oral 100mg 1 cap twice daily as needed for constipation c. A review of Patient 5's face sheet indicated she was admitted to the HHA agency on 10-26-22, with an admitting diagnosis of essential primary hypertension (abnormally high blood pressure) and diabetes (body’s ability to produce or respond to the hormone insulin is impaired). A review of Patient 5’s plan of care indicated skilled nurse visits once per week and physical therapy visits of 1x/week On 12-15-22, at 12 pm, during a home visit, the medication profile for Patient 5 was not current and updated. The following medications were not indicated in the current med profile and was not. Eliquis 200mg PO 1 tab 2x daily Pregabalin 75mg PO 1 tab 2x daily Atorvastin 30mg PO 1 tab 2x daily Ondansetron 4mg PO 1 tab as needed Amlodipine 5 mg 1 PO 1 tab daily On 12-16-22, at 11:30am, an interview was conducted in the conference room of the agency with ADM/DPCS. He acknowledged that the medication profile was not updated and should have been for Patients 4 and 5. ADM/DPCS stated that it is his responsibility to keep the medication profiles for all patients updated and current. ADM/DPCS further stated that it is important to have an updated med profile to ensure proper medication administration and safety for all patients. A review of the agency’s policy “Patient’s medication Documentation” dated 8-22-16, indicated the following: 1) all medications will be recorded, including non-prescription medications and medications no longer used. Medications not in use will be noted as such. 2) Patients will be given a copy of the medication sheet, and all new medications will be added to the medication sheet in the patients home. Findings: a. A review of Patient 1’s profile indicated a Start of Care (SOC) date of 4/27/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure that has multiple factors and does not have one distinct cause) and diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic chronic kidney disease (a type of kidney disease present over time caused by diabetes). A review of Patient 1’s Plan of Care (POC) for certification period from 10/24/2022 to 12/22/2022 indicated Skilled Nurse (SN) to visit once a week for nine weeks to reach the goal the patient/patient caregiver (PCG) will verbalize the understanding of medication management. The POC indicated Patient 1’s current medications as follows: - Amlodipine Besylate Oral 10 milligrams (mg, unit of weight) tablet, one tablet taken by mouth daily - Latanoprost-Timolol Maleate Ophthalmic 0.005-0.5%, give one drop daily - Timolol Maleate Ophthalmic 0.5%, give one drop daily in both eyes - Eszopiclone Oral 3mg tablets, give one tablet at bedtime - Levothyroxine Sodium Oral 75mcg (mcg, micrograms, unit of weight), give one tablet every morning before breakfast - Vitamin D2 50,000 units by mouth weekly - Furosemide Oral 20mg tablets, give one tablet daily - Simvastatin Oral 20mg tablets, give one tablet daily - Metformin HCL Oral 500mg tablets, give one tablet daily with food - Januvia Oral 100mg tablets, give one tablet daily A review of Patient 1’s Medication Profile provided on 12/14/2022 indicated the same medications and no changes of Patient 1’s POC. On 12/15/2022 at 10:02 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 2 at Patient 1’s home residence. Patient 1 was resting in bed watching television. Patient 1’s daughter/patient care giver (PCG) was in the home during the home visit. During a concurrent observation, interview, and review of Patient 1’s medications on 12/15/2022, at 10:11 AM, with Licensed Vocational Nurse (LVN) 2 of Patient 1’s Medication Profile, it was noted the following medications were not listed on the Medication Profile: - Synthroid 50mcg tablets, take ½ tablet daily - Farxiga 5mg tablets, take one tablet every morning - Ozempic 0.25-0.5mg injection, inject 0.25mg subcutaneously (situated or applied under the skin) every week - Freestyle Libre blood sugar monitoring device, change every 14 days The following medications were listed on the Medication Profile but were not present in Patient 1’s home: - Levothyroxine Sodium 75mcg - Vitamin D2 50,000 units - Furosemide 20mg - Metformin HCL 500mg LVN 2 stated the missing medication were discontinued. LVN 2 did not have Patient 1’s Medication Profile with her during the home visit. LVN 2 stated the importance of updating the Medication Profile is to ensure all disciplines involved with the care of the patient are aware of the patient’s current medications, to watch for any adverse reactions or side effects, and to ensure the patient is receiving the proper medication therapy. During an interview on 12/16/2022, at 10:09 AM, with Director of Patient Care Services (DPCS), the DPCS stated the review of the patient’s medications are supposed to be completed by the Skilled Nurse (SN) during every SN visit. DPCS stated if any changes are identified, the SN communicates with the HHA office, the DPCS will contact the doctor. DPCS stated Medication Profiles should be updated so that the SN can ensure the patient is taking all the correct medications, SN can monitor compliance, and assess for any side effects. A review of the HHA’s policy and procedure (P&P) titled, “Patient’s Medication Documentation”, revised 8/22/2016 indicated all medications will be recorded, including non-prescription medications and medications no longer used, medications not in use will be noted as such. The P&P indicated the medication sheet will indicate when the medication is new (N) (prescribed within the last 30 days) or changed © (dose of frequency changed within the last 60 days), the Registered Nurse (RN) or LVN will inquire about medication changes each visit and record any changes, patients will be given a copy of the medication sheet, and all new medications will be added to the medication sheet in the patient’s home, and the medications which may have a direct effect on identifiable laboratory values will be monitored by the skilled professional visiting the patient for any untoward effects.

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 observation, interview, and record review, the home health agency (HHA) failed to provide care as ordered in the Plan of Care (POC) for four of seven sampled patients (Patient 1, 2, 3, and 5). a. For Patient 1, the Skilled Nurse (SN) failed to assess and document the oxygen saturation (O2 sat, noninvasive test that measures the oxygen saturation level of your blood), fasting blood sugar level (FBS, the result of a blood sample taken after a patient has not had anything to eat or drink for at least eight hours), and assess the patient’s medications, and the certified home health aide (CHHA) failed to provide services as indicated in the Plan of Care (POC). b. For Patient 2, the HHA failed to update the POC with the patient’s medications as indicated on the POC and the HHA failed to provide SN visits as indicated in the POC. c. For Patient 3, the HHA failed to provide SN visits according to the POC. d. For Patient 5, the SN failed to assess the patient’s vital signs during the SN home visit as indicated on the POC. These deficient practices placed these patients at risk for not receiving ordered care as specified by the physician. d. A review of Patient 5's face sheet indicated she was admitted to the HHA agency on 10-26-22, with an admitting diagnosis of essential primary hypertension (abnormally high blood pressure) and diabetes (body’s ability to produce or respond to the hormone insulin is impaired). A review of patient 5’s plan of care indicated skilled nurse visits once per week and physical therapy visits of 1x/week On 12-14-22, during a record review of the agency’s document entitled “Home Health Certification and Plan of Care” with a certification period of 10-26-22 to 12-24-22, indicated that the SN was to perform skilled observation and vital sign assessment of the patient’s condition. The Plan of care further indicated that the physician should be notified of the following: Temperature greater than (>) 101 or less than ( Pulse greater than (>) 110 or less than ( Respiration greater than (>) 24 or less than ( Systolic BP greater than (>)160 or less than ( Diastolic BP greater than (>) 100 or less than ( O2 sat less than ( On 12-15-22, at 12 pm, during observation on a home visit, the ADM/DPCS did not take Patient 5's vital signs as ordered by the physician. On 12-15-22, at 1 pm, an interview was conducted with the ADM/DPCS stated Patient 5 was not his usual patient and he forgot to bring his bag containing his blood pressure cuff and stethoscope. ADM/DPCS further stated that vital signs are one of the first indicators of a patient’s changing condition. ADM/DPCS acknowledged vital signs were not taken and recorded for this visit and should have been done. A review of the agency’s policy “Care Planning Process” with a revised date of January 2005, indicated the following: 1 The Plan of Care will be based upon the physician’s orders and will encompass the services required to meet the patient’s needs. 2 Care decisions and services to be provided will be made as a result of the care planning process, analysis of the initial and ongoing assessments, and analysis of the patient response to care against goals and outcomes. 3 The Care Planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. Findings: a. A review of Patient 1’s profile indicated a Start of Care (SOC) date of 4/27/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure that has multiple factors and does not have one distinct cause) and diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic chronic kidney disease (a type of kidney disease present over time caused by diabetes). A review of Patient 1’s POC for certification period from 10/24/2022 to 12/22/2022 indicated SN to visit once a week for nine weeks to assess the patient’s vital signs (VS, clinical measurements that indicate the state of a patient’s essential body functions including pulse rate, temperature, respiration rate, and blood pressure). The POC indicated the SN to notify the doctor if the patients O2 sat is less than 90%, if the FBS is greater than 250 or less than 60. The POC indicated CHHA to visit twice a week for nine weeks to provide bathing, grooming, and personal hygiene. The POC indicated Patient 1’s current medications as follows: - Amlodipine Besylate Oral 10 milligrams (mg, unit of weight) tablet, one tablet taken by mouth daily - Latanoprost-Timolol Maleate Ophthalmic 0.005-0.5%, give one drop daily - Timolol Maleate Ophthalmic 0.5%, give one drop daily in both eyes - Eszopiclone Oral 3mg tablets, give one tablet at bedtime - Levothyroxine Sodium Oral 75 micrograms (mcg, unit of weight), give one tablet every morning before breakfast - Vitamin D2 50,000 units by mouth weekly - Furosemide Oral 20mg tablets, give one tablet daily - Simvastatin Oral 20mg tablets, give one tablet daily - Metformin HCL Oral 500mg tablets, give one tablet daily with food - Januvia Oral 100mg tablets, give one tablet daily A review of Patient 1’s Medication Profile provided on 12/14/2022 indicated the same medications as on Patient 1’s POC. During an interview on 12/14/2022, at 2:13 PM with Director of Patient Care Services (DPCS), DPCS stated the SN and CHHA visit notes should be input into the electronic charting system as soon as possible or within five to seven days. On 12/15/2022, at 10:02 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 2 at Patient 1’s home residence. Patient 1 was resting in bed watching television. Patient 1’s daughter/patient care giver (PCG) was in the home during the home visit. During a concurrent observation, interview, and review of Patient 1’s medications on 12/15/2022, at 10:11, AM with LVN 2 of Patient 1’s Medication Profile, it was noted that the following medications were not listed on the Medication Profile: - Synthroid 50mcg tablets, take ½ tablet daily - Farxiga 5mg tablets, take one tablet every morning - Ozempic 0.25-0.5mg injection, inject 0.25mg subcutaneously (SQ, situated or applied under the skin) every week - Freestyle Libre blood sugar monitoring device, change every 14 days The following medications were listed on the Medication Profile but were not present in Patient 1’s home: - Levothyroxine Sodium 75mcg - Vitamin D2 50,000 units - Furosemide 20mg Metformin HCL 500mg LVN 2 stated the missing medications were discontinued. LVN 2 did not have a Medication Profile with her or present in Patient 1’s home. LVN 2 stated the importance of updating the Medication Profile is to ensure all disciplines involved with the care of the patient are aware of the patient’s current medications, to watch for any adverse reactions or side effects, and to ensure the patient is receiving the proper medication therapy. During a concurrent interview and record review on 12/15/2022 at 10:26 AM with LVN 2 of Patient 1’s Skilled Nursing Visit notes, LVN 2 verified Skilled Nursing Visit notes dated 11/30/2022 and 12/5/2022 did not have an O2 sat documented, the notes indicated patient is on room air, the patient has shortness of breath (SOB) when walking more than 20 feet, climbing stairs. LVN 2 stated there should be an actual number percentage documented to assess the patient’s O2 sat. During a concurrent interview and record review on 12/15/2022, at 10:26 AM, with LVN 2 of Patient 1’s Skilled Nursing Visit notes, LVN 2 verified Skilled Nursing Visit note dated 12/12/2022 did not have a FBS documented for a diabetic patient. LVN 2 stated there should be an actual number documented to assess if the patient has low or high blood sugar level. During a concurrent interview and record review on 12/16/2022, at 10:09 AM, with DPCS of Patient 1’s Skilled Nurse Visit notes, CHHA visit notes, and the medications on the POC, the DPCS stated the review of the patient’s medications are supposed to be completed by the SN during every SN visit. DPCS stated if any changes are identified, the SN communicates with the HHA office, the DPCS will contact the doctor. DPCS stated the SN should assess the patient’s medications during every SN visit to ensure the patient is taking all the correct medications, SN can monitor compliance, and assess for any side effects. The DPCS verified Patient 1’s Skilled Nurse Visit notes dated 11/30/2022 and 12/5/2022 do not have an O2 sat documented for the patient who experiences SOB when walking more than 20 feet or climbing stairs. The DPCS stated O2 sat is part of the VS assessed by the SN, if there is no O2 sat documented, it could mean it was not assessed. DPCS stated it’s important to assess the O2 sat to identify any incidence of low oxygen levels per the parameters (set of limits) as indicated on the patient’s POC. The DPCS verified Patient 1’s Skilled Nurse Visit note dated 12/12/2022 did not have a FBS documented for a diabetic patient. DPCS stated the SN should assess and document the FBS for a diabetic patient to monitor and identify any low or high blood sugar episodes. The DPCS verified Patient 1’s POC indicated CHHA to provide bathing, grooming, and personal hygiene for the patient. DPCS verified CHHA visit note dated 10/29/2022 indicated the CHHA assessed Patient 1’s VS only but no other procedures were documented. DPCS stated the importance to document what procedures the CHHA performed to ensure the patient receives the necessary services according to the POC. b. A review of Patient 2’s profile indicated a SOC date of 11/22/2022 with a primary diagnosis of Ehlers-Danlos syndrome (a group of inherited disorders that affect connective tissues supporting the skin, bones, blood vessels, and many other organs and tissues) and fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues). A review of Patient 2’s POC for certification period from 11/22/2022 to 1/20/2023 indicated SN to visit twice a week for one week, then once a week for seven weeks. The POC does not indicate the medications Patient 2’s doctor ordered. A review of Patient 2’s Medication Profile indicated the following medications on order: - Oxycodone HCL 10 mg - Neurontin Oral 600 mg - Motrin IB Oral 200 mg - Magnesium Glycinate Oral 100 mg - Ativan Oral 2 mg - Lunesta Oral 2 mg - Abilify Oran 5 mg During a concurrent interview and Patient 2’s electronic record review on 12/16/2022, at 10:09 AM, with the HHA’s DPCS, verified there were no SN visits documented on 12/2/2022 and 12/6/2022. DPCS was unable to provide any evidence the SN visited Patient 2. DPCS stated he did not know why the SN visits were not done. DPCS verified Patient 2’s POC does not reflect the medications according to the doctor’s orders. DPCS stated the importance for the POC to reflect the patient’s medications to ensure the patient is taking the prescribed medications as ordered by the doctor and to monitor progress of therapy. c. A review of Patient 3’s profile indicated a SOC date of 12/28/2021 with a primary diagnosis of essential primary HTN and radiculopathy of lumbar region (inflammation of a nerve root in the lower back which causes pain or irritation in the back and down the legs). A review of Patient 3’s POC for certification period from 6/26/2022 to 8/24/2022 indicated SN to visit once a week for nine weeks. During a concurrent interview and Patient 3’s electronic record review on 12/16/2022 at 10:09 AM with the HHA’s DPCS, DPCS verified there were no SN visits documented after the resumption of care assessment on 6/24/2022. DPCS was unable to provide any evidence any SN visits for Patient 3 were conducted between 6/24/2022 and Patient 3’s discharge date of 7/8/2022. DPCS stated he did not know why the SN visits were not done. A review of the HHA’s policy and procedure (P&P) titled, “Care Planning Process”, revised 1/2005, indicated the purpose is to provide clinical direction to clinicians providing direct patient care. The P&P indicated all clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including, but not limited to clinical drug monitoring. The P&P indicated based on the assessment and conclusions, the POC will include, but not be limited to specific services to be provided. It indicated the POC will be based on the physician’s orders, and the POC will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient and those revision dates will be noted on the POC. A review of the HHA’s P&P titled, “Recertification Plans of Care”, revised 8/22/2016 indicated the purpose to assure that patient care plans are current and accurate and individualized. The P&P indicated the primary service will verify all physician’s orders and record them for inclusion in the recertification POC. A review of the HHA’s P&P titled, “Reporting of Significant Changes”, revised 8/22/2016 indicated skilled professionals shall report all significant changes in the client’s condition to the physician at the time the changes are assessed. The P&P indicated any changes include VS outside the goal range established in the patient’s plan of treatment, or outside the goal range established by the physician on a supplemental order and blood glucose levels outside of the goal range established in the patient’s POC, or outside the goal range established by the physician via supplemental order. A review of the HHA’s P&P titled, “Home Health Aide Services/Supervisory Visit Administrative Policy”, revised 8/22/2016, indicated the home health aide services shall be in accordance with the POC, duties of the home health aide shall include: - assisting clients with bath, care of mouth, skin, and hair - assist clients in and out of bed and assisting with ambulation - assist clients to bathroom or in nursing bedpan - complete appropriate records.

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 observation, interview, and record review, the home health agency (HHA) failed to follow the doctor’s order for levothyroxine (a medication used to treat an underactive thyroid gland which helps to control energy levels and growth) and identify other medications as ordered by the doctor for one of seven (Patient 1) sampled patients. This deficient practice had the potential for the patient to experience adverse reactions and ineffective therapy for not following the doctor’s orders. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 4/27/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure that has multiple factors and does not have one distinct cause) and diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic chronic kidney disease (a type of kidney disease present over time caused by diabetes). A review of Patient 1’s POC for certification period from 10/24/2022 to 12/22/2022 indicated SN to visit once a week for nine weeks. The POC indicated recertification was recommended to continue the POC that requires additional time to monitor blood pressure levels and medication compliance. The POC indicated Patient 1’s current medications as follows: - Amlodipine Besylate Oral 10 milligrams (mg, unit of weight) tablet, one tablet taken by mouth daily - Latanoprost-Timolol Maleate Ophthalmic 0.005-0.5%, give one drop daily - Timolol Maleate Ophthalmic 0.5%, give one drop daily in both eyes - Eszopiclone Oral 3mg tablets, give one tablet at bedtime - Levothyroxine Sodium Oral 75 micrograms (mcg, unit of weight), give one tablet every morning before breakfast - Vitamin D2 50,000 units by mouth weekly - Furosemide Oral 20mg tablets, give one tablet daily - Simvastatin Oral 20mg tablets, give one tablet daily - Metformin HCL Oral 500mg tablets, give one tablet daily with food - Januvia Oral 100mg tablets, give one tablet daily A review of Patient 1’s Medication Profile provided on 12/14/2022 indicated the same medications and no changes as indicated in Patient 1’s POC. On 12/15/2022, at 10:02 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 2 at Patient 1’s home residence. Patient 1 was resting in bed watching television. Patient 1’s daughter/patient care giver (PCG) was in the home during the home visit. During a concurrent observation, interview, and review of Patient 1’s medications on 12/15/2022, at 10:11 AM, with LVN 2 of Patient 1’s Medication Profile, it was noted that the following medications were not listed in the Medication Profile: - Synthroid 50mcg tablets, take ½ tablet daily - Farxiga 5mg tablets, take one tablet every morning - Ozempic 0.25-0.5mg injection, inject 0.25mg subcutaneously (SQ, situated or applied under the skin) every week - Freestyle Libre blood sugar monitoring device, change every 14 days The following medications were listed on the Medication Profile but were not present in Patient 1’s home: - Levothyroxine Sodium 75mcg - Vitamin D2 50,000 units - Furosemide 20mg - Metformin HCL 500mg LVN 2 stated the missing medications were discontinued. LVN 2 did not have a Medication Profile with her or present in Patient 1’s home. LVN 2 stated the importance of updating the Medication Profile is to ensure all disciplines involved with the care of the patient are aware of the patient’s current medications, to watch for any adverse reactions or side effects, and to ensure the patient is receiving the proper medication therapy. During an interview on 12/16/2022 at 10:09 AM with Director of Patient Care Services (DPCS), the DPCS stated the Skilled Nurse (SN) should review the patient’s medications during every SN visit to ensure the doctor’s orders are being followed. DPCS stated if there are any changes in medications, the SN communicates with the HHA office, the DPCS will contact the doctor to verify the changes. DPCS stated Medication Profiles should be updated so that the SN can ensure the patient is taking all the correct medications as ordered by the doctor, the SN can monitor compliance, and assess for any side effects. A review of the HHA’s policy and procedure (P&P) titled, “Physician’s Role”, revised 8/22/2016, indicated the agency obtains complete orders for care including prescribed medications with dose, route and frequency of administration. The P&P indicated care delivery follows the plan of care, staff administers medications only as ordered by the doctor. A review of the HHA’s P&P titled, “Patient’s Medication Documentation”, revised 8/22/2016 indicated all medications will be recorded, including non-prescription medications and medications no longer used, medications not in use will be noted as such. The P&P indicated the medication sheet will indicate when the medication is new (N) (prescribed within the last 30 days) or changed © (dose of frequency changed within the last 60 days), the Registered Nurse (RN) or LVN will inquire about medication changes each visit and record any changes, a doctor’s order form will be initiated at all times whenever a medication is changed or a medication is discontinued, patients will be given a copy of the medication sheet, and all new medications will be added to the medication sheet in the patient’s home.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to communicate the inaccuracies of the medications for one of seven (Patient 1) sampled patients. This deficient practice had the potential of the patient receiving inappropriate medication therapy. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 4/27/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure that has multiple factors and does not have one distinct cause) and diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic chronic kidney disease (a type of kidney disease present over time caused by diabetes). A review of Patient 1’s Plan of Care for certification period from 10/24/2022 to 12/22/2022 indicated Skilled Nurse (SN) to visit once a week for nine weeks. The POC indicated recertification was recommended to continue the POC that requires additional time to monitor blood pressure levels and medication compliance. The POC indicated Patient 1’s current medications as follows: - Amlodipine Besylate Oral 10 milligrams (mg, unit of weight) tablet, one tablet taken by mouth daily - Latanoprost-Timolol Maleate Ophthalmic 0.005-0.5%, give one drop daily - Timolol Maleate Ophthalmic 0.5%, give one drop daily in both eyes - Eszopiclone Oral 3mg tablets, give one tablet at bedtime - Levothyroxine Sodium Oral 75 micrograms (mcg, unit of weight), give one tablet every morning before breakfast - Vitamin D2 50,000 units by mouth weekly - Furosemide Oral 20mg tablets, give one tablet daily - Simvastatin Oral 20mg tablets, give one tablet daily - Metformin HCL Oral 500mg tablets, give one tablet daily with food - Januvia Oral 100mg tablets, give one tablet daily A review of Patient 1’s Medication Profile provided on 12/14/2022 indicated the same medications as indicated in Patient 1’s POC. On 12/15/2022, at 10:02 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 2 at Patient 1’s home residence. Patient 1 was resting in bed watching television. Patient 1’s daughter/patient care giver (PCG) was in the home during the home visit. During a concurrent observation, interview, and review of Patient 1’s medications on 12/15/2022, at 10:11 AM, with LVN 2 of Patient 1’s Medication Profile, it was noted that the following medications were not listed on the Medication Profile: - Synthroid 50mcg tablets, take ½ tablet daily - Farxiga 5mg tablets, take one tablet every morning - Ozempic 0.25-0.5mg injection, inject 0.25mg subcutaneously (SQ, situated or applied under the skin) every week - Freestyle Libre blood sugar monitoring device, change every 14 days The following medications were listed on the Medication Profile but were not present in Patient 1’s home: - Levothyroxine Sodium 75mcg - Vitamin D2 50,000 units - Furosemide 20mg - Metformin HCL 500mg LVN 2 stated the missing medications were discontinued. LVN 2 verified the Medication Profile did not indicate the medications were discontinued and the new medications were not added to the profile. LVN 2 stated she communicated with the HHA about the changes in Patient 1’s medications and the HHA was supposed to communicate with the doctor about the changes. LVN 2 stated she does not know why the Medication Profile had not been updated to reflect the discontinued medications and the new medications. During an interview on 12/16/2022 at 10:09 AM with Director of Patient Care Services (DPCS), the DPCS stated the Skilled Nurse (SN) communicates with the HHA office if there are any changes in medications, then the DPCS will contact the doctor to verify the changes. DPCS stated the importance of communicating with the doctor regarding any discontinued or new medications and update the Medication Profile so that the SN can ensure the patient is taking all the correct medications as ordered by the doctor, the SN can monitor compliance, and assess for any side effects. The DPCS was unable to provide any documentation regarding any communication with the doctor of any changes in Patient 1’s medications. A review of the HHA’s policy and procedure (P&P) titled, “Patient’s Medication Documentation”, revised 8/22/2016, indicated the doctor will be notified of all medications and of all deviations from the prescribed manner of administration and the doctor will be informed of all non-compliance with the medication regimen. A review of the HHA’s P&P titled, “Physician’s Role”, revised 8/22/2016, indicated professional staff notifies the physician if required and documents according to any problems identified during the assessment of medications the patient may take and medication errors. A review of the HHA’s P&P titled, “Communication Notes”, revised 8/22/2016, indicated each person receiving a report of patient care, patient condition, or patient communication shall document the report on a Communication Note for inclusion in the medical record.

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 record review, the home health agency (HHA) failed to conduct and document supervisory visits for the certified home health aide (CHHA) no less frequently than every 14 days for one of seven (Patient 1) sampled patients. This deficient practice has the potential for the patient not receive the proper care from the CHHA. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 4/27/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure that has multiple factors and does not have one distinct cause) and diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic chronic kidney disease (a type of kidney disease present over time caused by diabetes). A review of Patient 1’s Plan of Care for certification period from 10/24/2022 to 12/22/2022 indicated CHHA to visit twice a week for nine weeks. The POC indicated CHHA to provide bathing, grooming, and personal hygiene. On 12/15/2022 at 10:02 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 2 at Patient 1’s home residence. Patient 1 was resting in bed watching television. Patient 1’s daughter/patient care giver (PCG) was in the home during the home visit. During a concurrent interview and record review on 12/16/2022, at 10:09 AM, with Director of Patient Care Services (DPCS) of Patient 1’s electronic medical chart, DPCS stated CHHA supervisory visits should be conducted every 14 days to monitor the duties provided by the CHHA. DPCS verified no supervisory visits had been conducted since the start of the current certification period of 10/24/2022 to 12/22/2022. DPCS was unable to provide any evidence that any supervisory visits were conducted during that certification period. A review of the HHA’s policy and procedure (P&P) titled, “Home Health Aide Services/Supervisory Visit Administrative Policy”, revised 8/22/2016, indicated the home health aide shall be supervised by the Registered Nurse every two weeks.

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 home health agency (HHA) failed to send the discharge summary to the primary doctor within five days of discharge for one of seven (Patient 3) sampled patients. This deficient practice resulted in the primary doctor not being informed of the discharge disposition of the patient. Findings: A closed record review of Patient 3’s profile indicated a Start of Care date of 12/28/2021 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure that has multiple factors and does not have one distinct cause) and radiculopathy of lumbar region (inflammation of a nerve root in the lower back which causes pain or irritation in the back and down the legs). A closed record review of Patient 3’s Plan of Care for certification period from 6/26/2022 to 8/24/2022 indicated SN to visit once a week for nine weeks. A closed record review of Patient 3’s Physician Order, dated 7/8/2022, indicated a doctor’s order to discharge Patient 3 from HHA services due to the patient refused services. A closed record review of Patient 3’s Discharge Summary, dated 7/8/2022, indicated the summary was completed on 7/8/2022 and Patient 3’s discharge date was 7/8/2022 due to patient refused assistance/care. During an interview on 12/14/2022, at 2:13 PM, with the Director of Patient Care Services (DPCS), DPCS stated a patient’s Discharge Summary should be sent to the doctor for signature within five days of patient discharge. During a concurrent interview and electronic closed record review on 12/16/2022, at 10:09 AM, with DPCS of Patient 3’s electronic medical record, DPCS verified Patient 3 was discharged on 7/8/2022 but there is no documentation the Discharge Summary was sent to the doctor within five days of Patient 3’s discharge. DPCS stated the Discharge Summary should be sent to the doctor within five days of the patient’s discharge. DPCS was unable to provide any evidence of documentation Patient 3’s Discharge Summary was sent to the doctor within five days of the patient’s discharge. A review of the HHA’s policy and procedure (P&P) titled, “Transfer/Discharge from Services”, revised 8/22/2016, indicated within five days after discharge, the skilled nurse completes a discharge summary and submits the original copy for transcription and filing in the clinical record and makes the availability of the discharge summary known to the physician, and provides a copy, if requested.