Health Care Solutions Services, Inc.

“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 a documented facility-based and community-based risk assessment, utilizing an all-hazards approach. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 7/16/26, and showed an undated documentation of facility-based and community-based risk assessment that included event, probability, human impact, property impact, business impact, preparedness, internal response, external response and risk percentage. On 7/16/26 at 0846 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was asked to show documented evidence when the facility-based and community-based risk assessment were conducted. The Administrator/DPCS acknowledged it should have been dated.”

“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), §485.542(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 record review, the agency failed to ensure the emergency preparedness plan included a process for cooperation and collaboration with tribal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 7/16/26, showed all the local, regional, State, and Federal emergency preparedness officials’ emergency contact information. * However, there was no documented evidence showing a process for cooperation and collaboration with the tribal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. On 7/16/26 at 0849 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above 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), §485.542(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 record review, the agency failed to ensure the emergency preparedness policies and procedures were reviewed and updated at least every 2 years. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s emergency preparedness program documents were conducted on 7/16/26. The agency’s emergency preparedness program showed no documented evidence the agency had reviewed and updated the emergency preparedness policies and procedures, based on the emergency plan risk assessment and the communication plan at least every 2 years. On 7/16/26 at 0855 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above 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 record review, the agency failed to ensure the emergency preparedness plan included the procedures to inform State and local emergency preparedness officials about 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 failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 7/16/26, and showed the plan did not include the policies and procedures to inform State and local emergency preparedness officials about 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. On 7/16/26 at 0901 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above 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 record review, the agency failed to ensure the emergency preparedness plan included 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. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 7/16/26, and showed no documented evidence the procedures addressing the HHAs must inform local and state officials of any on-duty staff or patients that they are unable to contact. On 7/16/26 at 0912 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above finding.”

“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), §485.542(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 interview and record review, the agency failed to ensure the emergency preparedness program included a communication plan which was reviewed and updated at least every 2 years. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 7/16/26. There was no documented evidence of the written emergency communication plan containing how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments was reviewed and updated every two years. On 7/16/26 at 0918 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above 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), §485.542(c)(4)-(6), §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 interview and record review, the agency failed to ensure their emergency preparedness plan included a method for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events Findings: Review of the agency’s emergency preparedness program documents was conducted on 7/16/26, and showed no documented evidence of a method for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care. On 7/16/26 at 0926 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above 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), §485.542(c)(7), §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 record review, the agency failed to ensure the emergency preparedness 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 potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 7/16/26, and showed no documented evidence of a communication plan to 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 7/16/26 at 1001 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above finding.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OASIS data were transmitted within 30 days of completing the asessments. This failure had the potential for not reporting and coordinating the patient care and services of the agency. Findings: Review of the HHA Error Summary Report Report Period dated 1/1/24 to 7/14/26, showed 15 OASIS data sets were submitted more than 30 days from the assessment completion date. On 7/16/26 at 1040 hours, an interview and concurrent document review were conducted with the Administrator/DPCS. The Administrator/DPCS acknowledged the findings.”

“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 record review, the agency failed to complete the initial comprehensive assessment in a timely manner consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care for four of eight sampled patients (Patients 1, 2, 3, and 5). This failure had the potential to affect the identification of patient needs, delay the development of an appropriate plan of care, and adversely impact the delivery of safe and effective home health services. Findings: Review of the agency’s P and P titled Reporting, Transmission, and confidentiality of OASIS Data information dated 8/8/02, showed The OASIS comprehensive assessments will be completed in a timely manner consistent with the patient’s immediate needs: a.The initial assessment must be completed no later than 5 calendar days after the start of care; b.Will be completed as frequently as the condition of the patient required, but not less frequently than every second calendar month beginning with the start of care (no earlier than 5 days before and no later than one day before the calendar day on which care began); c.When the plan of care is revised for physician review; d.Within 48 hours of the patient’s return home from the hospital, and e.When the patient is discharged. 2.The comprehensive assessment updates must include the appropriate OASIS items as indicated on the data set. 1.Review of Patient 1’s clinical record was initiated on 7/14/26. The clinical record showed the start of care (SOC) date was 4/15/26. The patient was certified for hospice services during certification periods from 4/15/26 to 6/13/26, and from 6/14/26to 8/12/26.Review of the OASIS E2 – Start of Care form dated 4/15/26 showed under Section F (Preferences for Customary Routine Activities), the item for refused care was left blank. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake coordinator/ Case manager/Licensed Vocational Nurse. The Intake coordinator/ Case manager/Licensed Vocational Nurse was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 6/19/26. The patient was certified for hospice services during the certification period from 6/19/26 to 8/17/26. Review of the OASIS E1 – Start of Care form dated 6/19/26 showed under Section H (Bowel and Bladder), mastectomy right and left and the corresponding dates were left blank. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake coordinator/ Case manager/Licensed Vocational Nurse. The the Intake coordinator/ Case manager/Licensed Vocational Nurse was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 1/8/26. The patient was certified for hospice services during the certification periods from 1/8/26 to 3/8/26, from 3/9/26 to 7/6/26, and from 7/7/26 to 9/4/26. Review of the OASIS E1-Start of Care form dated 1/8/26 showed the following: Under Section F (Preferences for Customary Routine Activities), living arrangements showed Patient 5 lives in a congregate setting; however, the name of the facility, caregiver, and contact information were left blank.Under Section H (Bowel and Bladder), gyneco‑urinary was left blank.Under Section O (Special Treatment, Procedures, and Programs), DME supplies were documented as blank.On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake coordinator/ Case manager/Licensed Vocational Nurse. The Intake coordinator/ Case manager/Licensed Vocational Nurse was informed and acknowledged the findings. 3. Review of Patient 2’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 9/19/25. The patient was certified for hospice services during certification periods from 9/19/25 - 11/17/25, 11/18/25 - 1/16/26, 1/17/26 - 3/17/26, 3/18/26 - 5/16/26 and 5/17/26 - 7/15/26. Review of the OASIS E2 – Start of Care form dated 9/19/25 showed completed assessments on cognitive, hearing, speech, vision mood, behavior, neurological, psychosocial, functional status, cardiopulmonary, swallowing, nutritional, endocrine, skin musculoskeletal gastrointestinal, and genitourinary assessments. *However, the assessment under gyneco-urinary section had a blank documentation. On 7/21/26 at 0859 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed of the blank documentation and verfied that it should have been completed.”

“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 completion of the updated comprehensive assessment within the last 5 days of every 60 days for one of eight sampled patients (Patient 1). This failure had the potential to result in an incomplete clinical picture and inadequate care planning for this patient. Findings: Review of the agency’s P&P titled Recertification/Reassessment dated 2009 showed the comprehensive assessment must be updated and revised every second calendar month, beginning with the start of care. A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress toward outcomes. The update of the comprehensive assessment must, at a minimum, include: A. Completion of all follow-up date items from OASIS and any changes in patient status. B. Drug regimen review of all medications for drug interactions, potential adverse effects and drug reactions, duplicative drug therapy, ineffective drug therapy, significant side effects, and significant drug interactions. C. For the remainder of the comprehensive assessment that does not include OASIS items or drug regimen review, limiting documentation to the changes in the patient’s assessment is acceptable. Review of Patient 1’s clinical record was initiated on 7/14/26. The clinical record showed the SOC was 4/15/26. The patient was certified for hospice services during the certification periods from 4/15/26 to 6/13/26 and from 6/14/26 to 8/12/26. Review of the OASIS E2 – Recertification form dated 6/10/26, showed under the cardiopulmonary assessment, the tuberculosis risk‑factor section was left blank. Under the care preferences/patient’s personal goals, the recertification goal was not indicated and left blank. The refused‑care section was also left blank. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse. The Intake Coordinator/Case Manager/Licensed Vocational Nurse was 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 record review, the agency failed to ensure the POC included the required components for two of eight sampled patients (Patients 1 and 2). This failure had the potential risk of not addressing the care needs for these patients. Findings: 1. Review of Patient 2’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 9/19/25. The patient was certified for home health services during certification periods from 9/19/25 to 11/17/25, 11/18/25 to 1/16/26, 1/17/26 to 3/17/26, 3/18/26 to 5/16/26, and 5/17/26 to 7/15/26. Review of the Home Health Certification and Plan of Care dated 5/17/26, for certification period from 5/17/26 to 7/15/26 showed a physician’s order of ondansetron (antiemetic) one tablet by mouth every 8 hours as needed for nausea. *However, there was no dosage indicated for ondansetron medication. On 7/15/26 at 1351 hours, an interview and record review were conducted with RN 1. RN 1 was informed and verified the finding. 2. Review of Patient 1’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 4/15/26. The patient was certified for home health services during certification periods from 4/15/26 to 6/13/26 and from 6/14/26 to 8/12/26. Review of the Home Health Certification and Plan of Care and Patient Medication Profile for certification period from 6/14/26 to 8/12/26, showed the following physician’s order: -On 4/14/26, amlodipine besylate (antihypertensive) 5 mg one tablet oral “Daily - PRN” for systolic blood pressure greater than 200/100 mmHg. * The physician’s order showed both daily and PRN. However, there was no frequency on the as needed basis. -On 6/5/26, Levothyroxine 50 mcg one tablet by mouth daily for six days then two tablets by mouth for one day. * However, the physician’s order did show not any discontinued date order or if there was clarification to continue the medication. On 7/16/26 at 1455 hours, an interview and record review were conducted with the Intake Coordinator/Case manager/LVN. The Intake Coordinator/Case Manager/LVN was informed of the finding.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure effective communication with the patient’s physician for one of eight sampled patients (Patient 3). This failure had the potential of not providing necessary care and services to these patients. Findings: Review of Patient 3’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 6/19/26. The patient was certified for home health services during the certification period from 6/19/26 to 8/17/26. A joint visit with the Intake Coordinator/Case Manager/Licensed Vocational Nurse was conducted on 7/16/26 at 1030 hours, to Patient 3’s board and care facility. Review of the physician order dated 2/12/26, showed hydralazine (antihypertensive) 10 mg orally every six hours as needed when systolic blood pressure more than 160 mmHg. Review of the Medication Administration Record for July 2026 showed hydralazine was administered because the patient had high blood pressure on 7/6, 7/7, 7/8, 7/10, and 7/16/26. On 7/16/26 at 1030 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse and Caregiver 1. Per Caregiver 1, Patient 3 had several episodes of high blood pressure, and they administered hydralazine as needed since the patient was readmitted on 6/19/26. Caregiver 1 stated they had informed the nurse who visited the patient that Patient 3 had been receiving high blood pressure medication. On 7/16/26 at 1310 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse. The Intake Coordinator/Case Manager/Licensed Vocational Nurse stated the nurse should have informed the home health physician the patient had been taking as‑needed high blood pressure medication. The Intake Coordinator/Case Manager/Licensed Vocational Nurse was not aware that hydralazine was being administered. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse. The Intake Coordinator/Case Manager/Licensed Vocational Nurse was informed and acknowledged the findings.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure an interdisciplinary case conference to discuss and coordinate care for one of eight sample Patients (Patient 1) was completed. This failure had the potential for not providing necessary care and services to the patient. Findings: Review of the agency’s P& P titled Case Conference/Progress Summary dated 4/16 showed case conference will be held at least every 60 days to review and discuss all multidisciplinary cases. A record will be kept indicating who participated in the meeting and which patients were discussed. A case conference/progress summary, written by the appropriate discipline(s) treating the patient, will be placed in the patient’s clinical record after each case conference meeting. Review of Patient 1’s clinical record was initiated on 7/14/26. The record indicated the SOC was 4/15/26. The patient was certified for home health services during the certification periods from 4/15/26 to 6/13/26 and from 6/14/26 to 8/12/26.Review of the case conference dated 6/10/26, showed the case conference was not completed as per the agency’s P&P. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse. The Intake Coordinator/Case Manager/Licensed Vocational Nurse stated case conferences should be completed and documented every 60 days. The Intake Coordinator/Case Manager/Licensed Vocational Nurse was informed of the findings and acknowledged the information.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure patient and caregiver education was provided for one of eight sampled patients (Patient 1). This failure had the potential for not providing necessary care and services to the patient. Findings: Review of Patient 1’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 4/15/26. The patient was certified for home health services during certification periods from 4/15/26 to 6/13/26 and from 6/14/26 to 8/12/26. Review of the Home Health Certification and Plan of Care for certification period from 6/14/26 to 8/12/26, showed the medications included amlodipine besylate (antihypertensive) 5 mg one tablet oral daily PRN for systolic blood pressure greater than 200/100 mmHg. The POC included to teach patient/caregiver regarding disease processes, risk factors, signs and symptoms of complications/exacerbations and actions too take, medications, signs and symptoms of infection, home safety, energy conservations, fall precautions, emergency and disaster planning, access to emergency aid/911 protocol, and sign and symptoms to report to the physician. Review of the Patient Medication Profile for episode period 6/14/26 to 8/12/26, showed amlodipine besylate 5 mg one tablet by mouth daily and PRN for systolic blood pressure greater than 200/100 mmHg. A joint home visit with Intake Coordinator/Case manager/LVN was conducted on 7/16/26 at 1455 hours, to Patient 1’s home. At 1535 hours, a medication profile record review and concurrent interview was conducted with Intake Coordinator/Case Manager/LVN. A bottle of amlodipine besylate 5 mg one tablet by mouth every day in the morning was observed to have an expiration date of 6/11/26. In addition, there was no documented evidence the SN teachings or education was provided to the patient and caregiver that was specific to expired medications and proper disposal of expired medications. The Intake Coordinator/Case Manager/LVN was 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 skilled professionals consistently completed the clinical records for three of eight sampled patients (Patients 1, 4, and 5). This failure had the potential for substandard healthcare outcome for these patients. Findings: Reveiw of the agnecy’s P&P titled Entries into the Clinical Record copyright 2009 showed to include the following: -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 within 5 days of the patient’s discharge; or after discharge from the HHA (if any) within 5 business days of the patient’s discharge. -a discharge summary must be sent to the primary care practitoner or other health care professional who will be responsible for providing care an services to the patient after discharge from the HHA (if any) within 5 business days of the date of the order for discharge from the responsible physician. 3. Review of Patient 4’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 1/16/26. The patient was certified for hospice services during certification periods from 1/16/26 to 3/16/26, 3/17/26 to 5/15/26, and 5/16/26 to 7/14/26. Review of Order dated 7/14/26 showed for discharge to home or self-care with discharge reason: no further home health care needed. Review of the Discharge Summary Note dated 7/14/26 showed only with patient’s name, MR# (medical record number) and SOC dated 1/16/26. However, all details for discharge summary was a blank documentation. On 7/21/26 at 1001 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed of the blank documentation and stated the assigned ST had not yet submitted to the HHA. The Administrator/DPCS verified it should have been completed within 5 days and was past due. Review of the agency’s P and P titled Entries into Clinical record dated 4/13 showed Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The record formal will be reviewed and updated as necessary. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: A. Patient consent, authorization, and elections forms, as applicable. 1.Review of Patient 1’s clinical record was initiated on 7/14/26. The clinical record showed the start of care (SOC) date was 4/15/26. The patient was certified for hospice services during certification periods from 4/15/26 to 6/13/26, and from 6/14/26to 8/12/26. Review of the Home Health Certification and Plan of Care from 4/15/26 to 6/13/26 showed that the advance directives section listed a health care representative. Review of the Patient Consent/Conditions of Admission dated 4/15/26 showed Patient 1 had an advance directive/living will/durable power of attorney, and the answer was documented as “yes.” Review of the Skilled Nursing Visit Notes dated 4/20/26, 5/6/26, 5/13/26, and 5/26/26 showed the section for advance directives was left blank. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake coordinator/ Case manager/Licensed Vocational Nurse. The Intake coordinator/ Case manager/Licensed Vocational Nurse was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 1/8/26. The patient was certified for hospice services during the certification periods from 1/8/26 to 3/8/26, from 26, from 3/9/26 to 7/6/26, and from 7/7/26 to 9/4/26. Review of the Home Health Certification and Plan of Care from 1/8/26 to 3/8/26 showed that the advance directives section listed a power of attorney and copy to follow. Review of the Patient Consent/Conditions of Admission dated 1/8/26 showed Patient 5 had an advance directive/living will/durable power of attorney, and the answer was documented as “yes.” Review of the Skilled Nursing Visit Notes dated 1/17/26, 1/29/26, 2/12/26, 2/19/26 and 2/26/26 showed the section for advance directives was documented as “ No”. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake coordinator/ Case manager/Licensed Vocational Nurse. The Intake coordinator/ Case manager/Licensed Vocational Nurse was informed and acknowledged the findings. Review of the agency’s P&P titled Entries into Clinical record dated 4/13 showed documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The record formal will be reviewed and updated as necessary. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: A. Patient consent, authorization, and elections forms, as applicable. 1. Review of Patient 1’s clinical record was initiated on 7/14/26. The clinical record showed SOC was 4/15/26. The patient was certified for home health services during certification periods from 4/15/26 to 6/13/26 and from 6/14/26to 8/12/26. Review of the Home Health Certification and Plan of Care from 4/15/26 to 6/13/26, showed the advance directives section listed a health care representative. Review of the Patient Consent/Conditions of Admission dated 4/15/26, showed Patient 1 had an advance directive/living will/durable power of attorney, and the answer was documented as “yes.” Review of the Skilled Nursing Visit Notes dated 4/20, 5/6, 5/13, and 5/26/26, showed the section for advance directive was left blank. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case manager/Licensed Vocational Nurse. The Intake Coordinator/Case Manager/Licensed Vocational Nurse was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 1/8/26. The patient was certified for home health services during the certification periods from 1/8/26 to 3/8/26, 3/9/26 to 7/6/26, and 7/7/26 to 9/4/26. Review of the Home Health Certification and Plan of Care from 1/8/26 to 3/8/26, showed the advance directive section listed a power of attorney and copy to follow. Review of the Patient Consent/Conditions of Admission dated 1/8/26, showed Patient 5 had an advance directive/living will/durable power of attorney, and the answer was documented as “yes.” Review of the Skilled Nursing Visit Notes dated 1/17/, 1/29, 2/12/, 2/19, and 2/26/26. showed the section for advance directives was documented as “ No.” On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake coordinator/Case Manager/Licensed Vocational Nurse. The Intake Coordinator/ Case Manager/Licensed Vocational Nurse was informed and acknowledged the findings. 3. Review of the agency’s P&P titled Entries into the Clinical Record copyright 2009 showed to include the following:-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 within 5 days of the patient’s discharge; or after discharge from the HHA (if any) within 5 business days of the patient’s discharge. -a discharge summary must be sent to the primary care practitoner or other health care professional who will be responsible for providing care an services to the patient after discharge from the HHA (if any) within 5 business days of the date of the order for discharge from the responsible physician. Review of Patient 4’s clinical record was initiated on 7/14/26. The clinical record showed the SOC date was 1/16/26. The patient was certified for hospice services during certification periods from 1/16/26 to 3/16/26, 3/17/26 to 5/15/26, and 5/16/26 to 7/14/26. Review of Order dated 7/14/26, showed for discharge to home or self-care with discharge reason: no further home health care needed. Review of the Discharge Summary Note dated 7/14/26, showed only with patient’s name, medical record number, and SOC dated 1/16/26. However, all details for the discharge summary was a blank documentation. On 7/21/26 at 1001 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed of the blank documentation and stated the assigned ST had not yet submitted the documentation to the HHA. The Administrator/DPCS verified it should have been completed within 5 days and was past due.”

“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 RN’s supervisory oversight of a licensed vocational nurse for one of eight sampled patients (Patient 1). This failure had the potential for persistent of poor practices performed by the LVN. Findings: Review of the agency’s P&P titled Responsibilities/Supervision of Clinical Services dated 4/16 showed LPN/LVN will be supervised by a registered nurse at least every 60 days or as directed by the State Practice Act, whichever is more frequent. Review of Patient 1’s clinical record was initiated on 7/14/26. The clinical record showed the SOC was 4/15/26. The patient was certified for home health services during certification periods from 4/15/26 to 6/13/26 and from 6/14/26 to 8/12/26. Review of the LVN Supervisory Visit dated 6/10/26, showed the form was not completed. On 7/21/26 at 0815 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse. The Intake Coordinator/Case Manager/Licensed Vocational Nurse stated the LVN supervisory visit should have been completed and documented on 6/10/26. The Intake Coordinator/Case Manager/Licensed Vocational Nurse 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 following: - The annual tuberculosis screening test for PT 1 was not available in the personnel file records. - The performance evaluation was not completed for Patient 1 as per the agency’s P&P. - The agency failed to ensure the sign‑in sheet for QAPI meetings to verify attendance. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the agency’s Executive Director/Administrator’s Job Description revised 1/2005 showed essential job functions/ responsibilities that included the following: -planning and directing operations to ensure the provision of adequate and appropriate care and services, -establishing and maintaining effective channels of communication, -evaluating services and programs, -coordinating with other program areas and management as appropriate, -maintaing currency on local trends and issues, -ensuring that appropriate service policies are devloped and implemented, -directing personnel in performance of their duties including admisiion, discharge and provision of service to patients, -assuring appropriate personnel supervision during all operating hours. Title 22 Section 74723 (Employee’s Health Examination and Health Records), showed the following: a) All agencies shall require health assessments and maintain health records for employees with direct patient contact. (b) A written health assessment of each employee who has direct patient contact shall: (1) Be required as a prerequisite of employment. (2) Be performed within six months prior to employment or within 15 days of assuming employment with the agency. (4) Provide for a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter using a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and Drug Administration (FDA). (d) An employee shall not be required to undergo the annual tuberculosis screening requirements of (c)(4) if the local health officer certifies in writing that less frequent testing may be conducted, and the rationale for less frequent testing is in accordance with applicable federal, state, and local requirements and established professional standards. (f) A health record for each employee who has direct patient contact shall: (1) Be maintained by the agency. (2) Include the records and pertinent documentation of health examinations. (4) Be retained for a minimum of three years following termination of employment. Review of the agency’s P&P titled Performance Evaluations undated showed a competency based perfomance evaluation will be conducted for all employees after 3 months of employment and at least annually therafter on the employee’s annivarsary hire date. XX. Review of the personnel files for the agency’s employees was conducted with the Administrator/DPCS on 7/20/26, and showed the following: 1. Administrator/ DPCS’s personnel file did not show any documentation of the initial TB screening health record, pre-employment physical examination and year 2024 annual physical examination health records. 2. RN 1’s personnel file did no show documentation of the initial TB screening health record and initial physical examination. 3. Chief Executive Officer/Chief Financial Officer/LVN’s personnel file did not show initial TB screening health record, initial physical examination and year 2024 annual physical examination health records. 4. LVN 1’spersonnel file did not show initial TB screening health record, and initial physical examination. 5. CHHA 1 personnel file did not show initial TB screening health record, initial physical examination, year 2024 and 2025 annual physical examination health records. 6. PT 1 personnel file did not show year 2024, 2025 and 2026 annual TB screening health records, In addition, the personnel file did not contain any record of performance evaluation was conducted after 3 months of employment and at least annually thereafter on the employee’s anniversary hire date. On 7/20/26 at 1510 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above findings. 7. Review of the agency’s P and P titled Organizational Performance undated, showed 4. Staff Functions Agency staff functions include the following Participation on Performance Improvement project teams either by selection or based on voluntary assignment according to interests, expertise, or knowledge •Participation as project team facilitators to help coordinate improvement of agency functions, prioritize activities, and report on status of performance improvement activities •Attendance at educational offerings, as appropriate •Offering input, suggestions, or recommendations lo project teams •Assisting in collection, management, and analysis of data •Contributing to communications process to enhance and coordinate performance improvement functions. 5.Professional Advisory Committee Professional Advisory Committee is composed of health care professional’s representative of services provided by the agency as well as consumers. It meets quarterly to review policies and procedures, provide consultation to staff, and make recommendations for improved patient care. On 07/20/2026 at 1430 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse (LVN). When asked to identify the date of the most recent quarterly meeting required for the agency’s clinical record review process, the LVN stated she did not remember. She reported that quarterly meetings are typically attended by the Intake Coordinator/Case Manager/LVN, the DPCS/Administrator, and the RN Supervisor. Upon request, the agency was unable to provide documentation of the quarterly meeting, including a sign‑in sheet to verify attendance. The Intake Coordinator/Case Manager/LVN was informed and acknowledged the findings. The agency’s P&P titled Appointment of Executive Dircetor/Administrator revised date 4/2016 showed the Governing Body will appoint the Executive Director/Administrator through a procedure established by the Governing Body. The Executive/Director/Administrator will be responsible for the day to day operations of the organization. Review of the agency’s Executive Director/Administrator’s Job Description revised 1/2005 showed the essential job functions/ responsibilities included the following: -planning and directing operations to ensure the provision of adequate and appropriate care and services, -establishing and maintaining effective channels of communication, -evaluating services and programs, -coordinating with other program areas and management as appropriate, -maintaing currency on local trends and issues, -ensuring that appropriate service policies are developed and implemented, -directing personnel in performance of their duties including admissiion, discharge and provision of service to patients, -assuring appropriate personnel supervision during all operating hours. 1. According to Title 22 Section 74723 (Employee’s Health Examination and Health Records), showed the following: a) All agencies shall require health assessments and maintain health records for employees with direct patient contact. (b) A written health assessment of each employee who has direct patient contact shall: (1) Be required as a prerequisite of employment. (2) Be performed within six months prior to employment or within 15 days of assuming employment with the agency. (4) Provide for a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter using a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and Drug Administration (FDA). (d) An employee shall not be required to undergo the annual tuberculosis screening requirements of (c)(4) if the local health officer certifies in writing that less frequent testing may be conducted, and the rationale for less frequent testing is in accordance with applicable federal, state, and local requirements and established professional standards. (f) A health record for each employee who has direct patient contact shall: (1) Be maintained by the agency. (2) Include the records and pertinent documentation of health examinations. (4) Be retained for a minimum of three years following termination of employment. On 7/20/26 at 1510 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS stated she left the HHA in the year 2018 and was rehired in the year 2020. Review of the personnel files for the agency’s employees was conducted with the Administrator/DPCS on 7/20/26, and showed the following: a. Administrator/ DPCS’s personnel file did not show any documentation the initial TB screening health record and pre-employment physical examination record were maintained by the agency. b. RN 1 was hired on 6/15/16. The personnel file did not show documentation of the initial TB screening health record and initial physical examination record were maintained by the agency. c. LVN 1 was hired on 4/1/22. LVN 1’s personnel file did not show initial TB screening health record and initial physical examination were maintained by the agency. d. CHHA 1 was hired on 1/3/2020. CHHA 1 personnel file did not show initial TB screening health record and initial physical examination maintained by the agency. e. PT 1 was hired on 11/3/23. The personnel file did not show for the years 2024, 2025, and 2026 an annual TB screening health record. On 7/20/26 at 1510 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. She was informed and acknowledged the above findings. 2. Review of the agency’s P&P titled Performance Evaluations undated showed a competency based perfomance evaluation will be conducted for all employees after 3 months of employment and at least annually therafter on the employee’s anniversary hire date. PT 1 was hired on 11/3/23. The personnel file did not contain any record of a performance evaluation conducted after 3 months of employment and at least annually thereafter on the employee’s anniversary hire date for the years 2024 and 2025 On 7/20/26 at 1510 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above findings. 3. Review of the agency’s P and P titled Organizational Performance undated, showed: -Agency staff functions include the following Participation on Performance Improvement project teams either by selection or based on voluntary assignment according to interests, expertise, or knowledge •Participation as project team facilitators to help coordinate improvement of agency functions, prioritize activities, and report on status of performance improvement activities •Attendance at educational offerings, as appropriate •Offering input, suggestions, or recommendations lo project teams •Assisting in collection, management, and analysis of data •Contributing to communications process to enhance and coordinate performance improvement functions. -Professional Advisory Committee is composed of health care professional’s representative of services provided by the agency as well as consumers. It meets quarterly to review policies and procedures, provide consultation to staff, and make recommendations for improved patient care. Review of the Quality Improvement Program Evaluation for 2026 was conducted. On 07/20/2026 at 1430 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse (LVN). When asked to identify the date of the most recent quarterly meeting required for the agency’s clinical record review process, the LVN stated she did not remember. She reported that quarterly meetings are typically attended by the Intake Coordinator/Case Manager/LVN, the DPCS/Administrator, and the RN Supervisor. Upon request, the agency was unable to provide documentation of the quarterly meeting, including a sign‑in sheet to verify attendance. The Intake Coordinator/Case Manager/LVN was informed and acknowledged the findings. The agency’s P&P titled Appointment of Executive Dircetor/Administrator revised date 4/2016 showed the Governing Body will appoint the Executive Director/Administrator through a procedure established by the Governing Body. The Executive/Director/Administrator will be responsible for the day to day operations of the organization. Review of the agency’s Executive Director/Administrator’s Job Description revised 1/2005 showed the essential job functions/ responsibilities included the following: -planning and directing operations to ensure the provision of adequate and appropriate care and services, -establishing and maintaining effective channels of communication, -evaluating services and programs, -coordinating with other program areas and management as appropriate, -maintaing currency on local trends and issues, -ensuring that appropriate service policies are developed and implemented, -directing personnel in performance of their duties including admissiion, discharge and provision of service to patients, -assuring appropriate personnel supervision during all operating hours. 1. According to Title 22 Section 74723 (Employee’s Health Examination and Health Records), showed the following: a) All agencies shall require health assessments and maintain health records for employees with direct patient contact. (b) A written health assessment of each employee who has direct patient contact shall: (1) Be required as a prerequisite of employment. (2) Be performed within six months prior to employment or within 15 days of assuming employment with the agency. (4) Provide for a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter using a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and Drug Administration (FDA). (d) An employee shall not be required to undergo the annual tuberculosis screening requirements of (c)(4) if the local health officer certifies in writing that less frequent testing may be conducted, and the rationale for less frequent testing is in accordance with applicable federal, state, and local requirements and established professional standards. Review of the personnel files for the agency’s employees was conducted with the Administrator/DPCS on 7/20/26, and showed the following: PT 1 was hired on 11/3/23. The personnel file did not show an annual TB screening health record for the years of 2024 and 2025, . On 7/20/26 at 1510 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. She was informed and acknowledged the above findings. 2. Review of the agency’s P&P titled Performance Evaluations undated showed a competency based performance evaluation will be conducted for all employees after 3 months of employment and at least annually thereafter on the employee’s anniversary hire date. PT 1 was hired on 11/3/23. The personnel file did not contain any record of a performance evaluation conducted after 3 months of employment and at least annually thereafter on the employee’s anniversary hire date for the years of 2024 and 2025 On 7/20/26 at 1510 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the above findings. 3. Review of the agency’s P&P titled Organizational Performance undated, showed the following: -Agency staff functions include the following: Participation on Performance Improvement project teams either by selection or based on voluntary assignment according to interests, expertise, or knowledge Participation as project team facilitators to help coordinate improvement of agency functions, prioritize activities, and report on status of performance improvement activities Attendance at educational offerings, as appropriate Offering input, suggestions, or recommendations lo project teams Assisting in collection, management, and analysis of data Contributing to communications process to enhance and coordinate performance improvement functions. -Professional Advisory Committee is composed of health care professional’s representative of services provided by the agency as well as consumers. It meets quarterly to review policies and procedures, provide consultation to staff, and make recommendations for improved patient care. Review of the Quality Improvement Program Evaluation for 2026 was conducted. However, there was no sign-in sheet showing the attendees for the Q On 07/20/2026 at 1430 hours, an interview and clinical record review were conducted with the Intake Coordinator/Case Manager/Licensed Vocational Nurse. When asked to identify the date of the most recent quarterly meeting required for the agency’s clinical record review process, the LVN stated she did not remember. She reported the quarterly meetings were typically attended by the Intake Coordinator/Case Manager/LVN, the DPCS/Administrator, and the RN Supervisor. Upon request, the agency was unable to provide documentation of the quarterly meeting, including a sign‑in sheet to verify attendance. The Intake Coordinator/Case Manager/LVN was informed and acknowledged the findings.”