Joy Health Care Services

“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 consistently included strategies for addressing emergency events identified by the risk assessment, creating the potential risk of not providing the necessary care and services to the patients during an emergency event. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/13/25. Documentation showed the HHA had priority levels related to potential emergencies. Documentation showed the scores of eight to 14 points required minimal to moderate attention for additional planning and preparation; and the scores of 15 to 27 points required immediate attention for additional planning and preparation. The 4th Quarter Hazard Vulnerability Analysis Documentation dated 10/23/24, showed the HHA had identified the following as potential emergencies with the corresponding scores: -Drought: 8 -Earthquake: 18 -Epidemic:12 -Flashflood:12 -Wildfires: 12 -Structural damage: 8 -Disease:8 -Public Shooting:18 Further review of the emergency preparedness program documents showed strategies for fire and earthquake. However, there was no documented evidence of the strategies developed to address other identified events like drought and public shooting. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness agency P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This failure created the risk of not effectively utilizing the available personnel during an emergency. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/13/25. The emergency preparedness program did not address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the communication plan included the contact information for the entities providing services under arrangement and patients’ physician, creating the risk of not able to contact or request for assistance during the emergency events. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/13/25. There was no documented evidence the communication plan included the contact information for some of the entities providing services under arrangement and the patients’ physician. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency communication plan included a primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies, creating the risk of not able to contact or request for assistance in the emergency events. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/13/25. The communication plan failed to include primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“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 the emergency preparedness communication plan included a method for sharing the information and medical documentation for the patients under the HHA’s care, as necessary, with other health providers to maintain the continuity of care. This failure created the risk of not providing the necessary care and services to the patients during the emergency events. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/13/25. The emergency preparedness communication plan did not include a method for sharing the information and medical documentation for the patients under the HHA’s care, as necessary, with other health providers to maintain the continuity of care. On 1/14/25 at 1100 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“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 communication plan included a means of providing information about the HHA’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, Incident Command Center, or designee. This failure posed the risk of not providing quality care to the patients during the emergency events. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/13/25. However, the emergency preparedness communication plan did not include a means of providing information about the HHA’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, Incident Command Center, or designee. On 1/14/25 at 1100 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“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 HHA failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets, creating the risk of not reporting and coordinating the patient care assessments timely for the patients receiving care and services at the agency. Findings: Review of the OASIS validation reports from 6/2024 to 1/2025 was initiated on 1/13/25, and showed the following: The agency’s OASIS Agency Final Validation reports from 06/2024, showed there were three OASIS data sets submitted more than 30 days from the assessment completion date. The agency’s OASIS Agency Final Validation reports from 07/2024, showed there were five OASIS data sets submitted more than 30 days from the assessment completion date. The agency’s OASIS Agency Final Validation reports from 09/2024, showed there were two OASIS data sets submitted more than 30 days from the assessment completion date. The agency’s OASIS Agency Final Validation reports from 10/2024, showed there were three OASIS data sets submitted more than 30 days from the assessment completion date. The agency’s OASIS Agency Final Validation reports from 11/2024, showed there was one OASIS data set submitted more than 30 days from the assessment completion date. On 1/14/25 at 1156 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the hospice failed to document the reasons for conducting or selecting the PIP for the 2023 and 2024 and consistently measure the progress achieved on these projects. This created the risk of not identifying the opportunity for improvement for care and services provided to the agency’s patients. Findings: The HHA’s P&P titled Performance Improvement Projects revised 03/2018, showed the agency will conduct performance improvement projects. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the agency’s services and operations. The agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. The agency should have one performance improvement project either in development, ongoing, or completed each calendar year. The agency decides, based on the QAPI program activities and data, what projects indicated and the priority of the projects. On 1/13/24 at 1413 hours, an interview was conducted with the Administrator. She stated the QAPI members meet quarterly. She stated the QAPI meeting included discussion of infection control program, patient satisfaction survey, fall reduction, record review, sentinel events, grievance, contractor audits, and any input from the case manager. She stated PIPs were also discussed during the meeting. She stated both 2023 and 2024 PIPs were still ongoing. Review of the QAPI meeting minutes from the 1st, 2nd, 3rd, and 4th quarters of 2023 and from the 1st, 2nd, and 3rd quarters of 2024, showed the HHA had conducted the quarterly QAPI meeting. Review of the Performance Improvement Project 2023 (undated) showed the program area was the “Adequacy of Documentation- need to improve documentation on OASIS to show patient eligibility of home health.” Documentation showed the problem included nursing and therapy initial assessment must be documented properly and should show the need for home heath in their OASIS report; and nursing and therapy were still not well versed with the new OASIS-E program. Documentation showed data source included QA record review of OASIS. Documentation included the list of possible solutions/actions taken and the expected outcome. Review of the Performance Improvement Project 2024 (undated) showed the program area was the “Adequacy of Documentation- Timeliness of Submission of clinical notes and improvement on documenting clinical notes.” Documentation showed the problem included based on chart audit conducted by the QAPI team, there was 10% tardiness on submission of paperwork, and it is affecting the billing. Documentation included the list of possible solutions/actions taken and the expected outcome. * However, there was no documented evidence of data indicating the HHA had a problem in the area targeted for improvement. There was no documented evidence of the result and progress of the performance improvement project conducted for the years of 2023 and 2024. There was no documented evidence the solutions/actions taken were reevaluated to ensure the effectiveness of implemented plan for improvement. On 1/14/25 at 1224 hours, an interview and concurrent agency document review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to implement and maintain the agency’s infection control program which included surveillance, identification, prevention, control, and investigation of infections. This failure had the potential for spread of infections. Findings: Review of the agency’s P&P titled Infection Control Surveillance System: Prioritized Risks Identified revised 3/2018 showed the following: -The agency will implement an infection control surveillance system for patients and staff. The definition of infections is based on the most common infections prevalent to agency’s services that are high volume, frequent infectious complications and have a high potential for prevention by staff and/or have an increased risk for negative patient outcomes. -Written reporting of infections will occur through documentation on the applicable log (patient or employee). -At least quarterly, the Director of Clinical Services and infection control and QAPI Committee will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patient and Employees form. -Problems and/or undesirable trends in infections will be identified, including potential significant agency acquired and/or community acquired infections. If such problems or undesirable trends are identified, the infection control and QAPI Committees will identify ant common factors that could have led to the transmission of the infections(s). -The committees will make recommendations for and implement improvement activities. Review of the infection control documents from the 1st, 2nd, 3rd, and 4th quarters of 2023 and from the 1st, 2nd, and 3rd quarters of 2024, showed the HHA had collected infection control cases for the patients. a. The total number of infection control cases reported in the Infection Control Quarterly Data Aggregation and Analysis was not consistent with the Patient Infection Control Log. For example: The 1st Quarter of 2024 Patient Infection Control Log showed there were nine infection cases. The 1st Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were eight infection cases, which was not consistent. The 2nd Quarter of 2024 Patient Infection Control Log showed there were twelve infection cases. The 2nd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were seven infection cases, which was not consistent. b. The type of infection control cases reported in the Infection Control Quarterly Data Aggregation and Analysis was not consistent with the Patient Infection Control Log. For example: The 3rd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were total of eight infection cases. There was one case of wound infection, four cases of UTI, one case of sepsis, one case of C-difficile, and one case of bone infection. The 3rd Quarter of 2024 Patient Infection Control Log showed there were 10 infection cases. There were three cases of wound infection, one case of ear infection, one case of bone infection, four cases of UTI, and one case of a combination of UTI/sepsis. * However, the number of the type of infection cases was not consistent related to wound, ear, and C-difficile infection. c. There was no documented evidence the agency had analyzed the data, thoroughly investigated for possible causes of infections, and implemented specific actions to minimize infections. For example: The 2nd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there was one case of UTI. The 3rd Quarter of 2024 Infection Control Quarterly Data Aggregation and Analysis showed there were four cases of UTI. The 3rd Quarter of 2024 QAPI under the infection control showed the agency continue to perform the monitoring. Documentation showed for four cases of UTI. The scheduled actions included improve data collection using EMR, improve reporting from PCG and staff, in-service on infection control will be provided to staff, family, patient, geographic served on distinguishing of signs and symptoms of infection, and universal precaution. * However, the agency failed to identify the increase in wound infection cases from the 2nd to the 3rd Quarter of 2024. There was no documented evidence the agency investigated for possible causes of infections. The action plans for the 1st, 2nd, and 3rd Quarter of 2024 QAPI had the same information. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the clinical records were complete, authenticated and accurate for five of seven sampled patients (Patients 1, 3, 4, 5, and 8), creating the risk of substandard care provided to these patients as their clinical information was not complete. The agency’s P&P titled Medical Record Entries and Authentication revised 3/2018 showed all medical record entries will be dated and authenticated. The procedure includes all entries in the medical records will be complete and appropriately authenticated, dated and timed. All entries in the medical records will be authenticated by staff signature and title. If automated clinical record system is used, authentication includes a signature and title or secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry, in accordance with the state law. 1. Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. a. Review of the Recertification OASIS dated 3/29/24, showed the RN had performed a comprehensive assessment. However, on the section for the RN’s attestation for the printed name/ signature and date was left blank. b. Review of the Case Conference for the certification period 3/30/24 to 5/28/24, showed a case conference was conducted. The participant in the case conference showed an RN. However, the section for the signature of supervisor and date was left blank. c. Review of the SN notes dated 3/9 and 3/11/24, showed the SN had performed an assessment. However, the section for the clinician signature, title and date was left blank. In addition, review of the clinical record showed a communication note dated 3/11/24. however, the section on the communication note for the staff name, signature and date was left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 8’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all body systems. Review of the Communication Note dated 12/9/24, showed a communication related to medication. However, the section for the staff name/signature and date was left blank. b. The POC for the certification period from 10/11/24 to 12/9/24, cited for PT evaluation and treatment. Review of the Physicians Order dated 10/30/24, showed an order to discharge with PT and follow up with MD. The order showed the staff name/signature and date. However, the section for the physicians name /signature was left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 3a. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. Review of the Home Health Aide Care Plan for the certification period from 11/10/24 to 1/8/25, showed the CHHA visit frequency, assignment for the every visit, special instructions, problems and goals. However, the section for the names, signature and dates for CHHA and the RN/Therapist were blank. On 1/14/25 at 1239 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. Review of the SN notes dated 11/14, 11/21 and 11/30/24, showed the SN had performed an assessment. However, the section for the clinician signature, title and date was left blank. In addition, review of the SN note dated 1/4/25, on the section of narrative note showed declined visit, was sleeping. However, the section for the clinician signature, title and date was left blank. c. Review of the communication notes dated 9/13/24, showed a communication order related to change in PT visit frequency. However, the section for the clinician signature, title and date was left blank. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 4. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC for the certification period from 11/4/24 to 1/2/25 cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems. Review of the SN visit notes dated 11/8, 11/15, 11/22 and 11/25/24 showed the SN had performed an assessment. However, review of the SN visit notes on the section of the clinician signature, title and date was left blank. In addition, review of the Communication Note dated 1/2/25, the section of the clinician signature, title and date was left blank. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 5. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. The SN note dated 11/21 and 11/27/24, showed the SN conducted the visits. * However, there was no documented evidence of the clinician’s electronic signature. On 1/14/24 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. Findings: The agency’s P&P titled Medical Record Entries and Authentication revised 3/2018 showed all the medical record entries will be dated and authenticated. The procedure includes all entries in the medical records will be complete and appropriately authenticated, dated and timed. All entries in the medical records will be authenticated by staff signature and title. If automated clinical record system is used, authentication includes a signature and title or secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry, in accordance with the state law. 1. Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. a. Review of the Recertification OASIS dated 3/29/24, showed the RN had performed a comprehensive assessment. However, on the section for the RN’s attestation for the printed name/ signature and date were left blank. b. Review of the Case Conference for the certification period 3/30/24 to 5/28/24, showed a case conference was conducted. The participant in the case conference showed an RN. However, the section for the signature of supervisor and date were left blank. c. Review of the SN notes dated 3/9 and 3/11/24, showed the SN had performed an assessment. However, the section for the clinician signature, title and date were left blank. In addition, review of the clinical record showed a communication note dated 3/11/24. However, the section on the communication note for the staff name, signature, and date were left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 8’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all the body systems. Review of the Communication Note dated 12/9/24, showed a communication related to medication. However, the section for the staff name/signature and date were left blank. b. The POC for the certification period from 10/11/24 to 12/9/24, cited for PT evaluation and treatment. Review of the Physician’s Order dated 10/30/24, showed an order to discharge with PT and follow up with MD. The order showed the staff name/signature and date. However, the section for the physician’s name /signature was left blank. On 1/14/24 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 3a. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. Review of the Home Health Aide Care Plan for the certification period from 11/10/24 to 1/8/25, showed the CHHA visit frequency, assignment for every visit, special instructions, problems and goals. However, the section for the names, signature, and dates for CHHA and the RN/Therapist were blank. On 1/14/25 at 1239 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. Review of the SN notes dated 11/14, 11/21, and 11/30/24, showed the SN had performed an assessment. However, the section for the clinician signature, title, and date were left blank. In addition, review of the SN note dated 1/4/25, on the section of narrative note showed declined visit, was sleeping. However, the section for the clinician signature, title, and date were left blank. c. Review of the communication notes dated 9/13/24, showed a communication order related to change in PT visit frequency. However, the section for the clinician signature, title, and date were left blank. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 4. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC for the certification period from 11/4/24 to 1/2/25 cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all the body systems. Review of the SN visit notes dated 11/8, 11/15, 11/22 and 11/25/24 showed the SN had performed an assessment. However, review of the SN visit notes on the section of the clinician signature, title and date was left blank. In addition, review of the Communication Note dated 1/2/25, the section of the clinician signature, title and date was left blank. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 5. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. The SN note dated 11/21 and 11/27/24, showed the SN conducted the visits. * However, there was no documented evidence of the clinician’s electronic signature. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure Patient A’s grievance was investigated as per the agency’s P&P. This failure had the potential for not resolving the patient’s complaint or grievance. Findings: The agency’s P&P titled Complaint Resolution (undated) showed the agency will investigate complaints made by a patient, including but not limited to treatment or care that is furnished or furnished inconsistently. The designated individual who will respond to and takes action to resolve complaints is the Director of Clinical Services. The action includes investigative measures based on the nature of the complaints. Review of the agency’s Grievance Log for the year 2023 showed a documentation of a complaint from Patient A. The date of incident was 7/29/23. The details of the complaint were related to the agency’s inability to provide PT services. Review of the agency’s Grievance Log showed an electronic mail dated 7/18/23, between the agency staff and PT providers related to PT visits. However, review of the agency’s Grievance Log failed to show documented evidence of an investigation conducted related to PT services. On 1/13/25 at 1423 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator was asked if they completed an investigation report. The Administrator replied, no. The Administrator was also asked if they interviewed the PT as part of the investigation. The Administrator replied, no. The Administrator was informed and acknowledged the findings.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide a complaint resolution to Patient A’s complaint as per agency’s P&P. This failure had the potential of not addressing the patient’s needs or grievance. Findings: The agency’s P&P titled Complaint Resolution (undated) showed to provide for a prompt and equitable resolution of complaints by patients. The purpose was to provide a mechanism for use by the patient to assure response, and if possible resolution of a complaint in a timely manner. The procedure includes to document the resolution of the complaint. The designated individual who will respond to and take action to resolve complaints is the Director of Clinical Services. The action includes complaint resolution is achieved in accordance with the established time frames. Review of the agency’s Grievance Log for the year 2023 showed a documentation of a complaint from Patient A. The date of incident was 7/29/23. The details of the complaint were related to the agency’s inability to provide PT services. Review of the Grievance Log showed an acknowledgement letter dated 8/2/23, was sent to the complainant. However, review of the Grievance Log failed to show a resolution of the complaint as per the agency’s P&P. In addition, review of the log failed to show a resolution letter was sent to the complainant. On 1/13/25 at 1423 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator was asked if they have a timeline to send a resolution letter. The Administrator replied as soon as possible when the investigation was completed, they have to send a resolution letter. The Administrator was informed and acknowledged the findings. Cross ref. G-478”

“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 ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient’s immediate needs, but no later than five calendar days after the SOC date for two of seven sampled patients (Patients 3 and 7), creating the risk of not identifying and addressing the care needs timely for these patients. 2. Review of Patient 7’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The start of care assessment dated 10/29/24, showed the patient had Stage 2 left heel pressure injury. * However, there was no documented evidence the SN assessed the wound odor and the appearance of the wound bed. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for hospice services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The OASIS Start of Care dated 9/11/24, showed the RN had performed the initial comprehensive assessment. However, there was no documented evidenced the RN had assessed the patients height and weight as the section was left blank. In addition, the section for the RN printed name, signature and date was left blank. On 1/14/25 at 1227 hours an interview and concurrent clinical record review was conducted with the LVN Care Coordinator, Administrator and HR Manager. They were informed and acknowledged the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included all of the patient’s current medications to identify any potential adverse effects and drug reactions for three of seven sampled patients (Patients 3, 4, and 5). This posed the risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. 3. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. a. The Medication Profile for the certification period from 11/20/24 to 1/18/25, showed the patient’s medication included losartan (antihypertensive) 50 mg one tablet PO once daily, amlodipine (antihypertensive) 2.5 mg PO one tablet PO one daily, Eliquis (anticoagulant) 5 mg one tablet PO Q 12 hours, pantoprazole (used to treat GERD) 40 mg one tablet PO once daily, Celecoxib (non-steroidal anti-inflammatory drug)100 mg one tablet PO PRN Q six hours for moderate pain, gabapentin (anticonvulsant) 100 mg one tablet PO once daily, alendronate (used to treat osteoporosis), loratadine (antihistamine) 10 mg one tablet PO once daily, and calcium carbonate (supplement) 500 mg once daily, Oxycodone (opioid analgesic) 5 mg one tablet PO Q four hours PRN for severe pain, tramadol (opioid analgesic) 50 mg PO Q four hours PRN for 7-10 pain rate (0= no pain 10 worst pain). Documentation showed the medications listed above have been reviewed for potential adverse effects and drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy. According to Celecoxib’s prescribing information, the significant drug interaction between Celecoxib and anticoagulants such as warfarin have a synergistic effect on bleeding. The concomitant use of Celecoxib and anticoagulants have an increased risk of serious bleeding compared to the use of either drug alone. * However, there was no documented evidence the HHA had identified the potential drug interaction between Celecoxib and Eliquis. b. The SN note dated 12/13/24, showed during the home health visit the patient was educated on the chemotherapy regimen with 5-fluorouracil (medication to treat cancer) and care of the port- a catheter. * However, the patient’s chemotherapy regimen with 5-fluorouracil as per the SN note dated 12/13/24 was not included in the medication profile. c. A joint home visit with RN 1 was conducted on 1/9/25 at 1000 hours, to Patient 4’s home. Review of the patient’s medications with the RN 1 showed the following: -Patient 4 was on Celecoxib 200 mg one capsule a day for pain. -Patient 4 was on gabapentin 100 mg one tablet BID, instead of once daily. -Patient 4 was on calcium carbonate 500 mg twice a day instead of once daily -Patient 4 stated Oxycodone was stopped in September and was not taking tramadol due to upset stomach. The patient stated tramadol was taken long time ago. The patient stated new medications included vitamin D3 (supplement) 125 mcg one tablet once daily and ferrous sulfate (supplement) 325 mg one tablet PO once daily,. * However, the patient’s medication profile was not updated. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. The agency’s P&P titled Medication Profile revised 3/18, showed all prescribed medications, over the counter (OTC) medications and home remedies will be documented on the medication profile. The nurse or therapist will add all new /changed medication(s) to the medication profile. The medication profile will be reviewed every home visit and updated as changes occur. 1. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The Medication Profile for the certification period from 11/10/24 to 1/8/25, showed the patient’s medications included lisinopril (ACE inhibitors) 5 mg tablet one tablet PO QD, Montelukast (anti -asthma) 10 mg one tablet PO QD, omeprazole (acid reflux), buspirone (anti- anxiety) 10 mg tablet one tablet PO QD, quetiapine (atypical antipsychotic) 50 mg tablet one tablet PO BID, escitalopram (SSRI’s) 10 mg tablet one tablet PO QD, memantine (memory loss), Vitamin D3 (supplement) 25 mcg capsule one capsule PO QD, docusate sodium (laxative) one capsule PO QD and Senna (laxative) 8.6 mg tablet one tablet PO BID. A joint home visit with CHHA was conducted on 1/8/25 at 1330 hours, to Patient 3’s home. Review of the patient’s medications with the PCG and the CHHA showed the patient was on Vitamin D3 (supplement) 5000 mcg capsule one capsule PO QD instead of 25 mcg as listed on the medication profile. In addition, patient was taking Severe Cold and Flu (Acetaminophen 325 mg) two tablets in the morning and PRN which was not listed on the medication profile. Moreover, the PCG reported the patient was not taking lisinopril 5 mg one tablet PO QD as instructed by the patients pulmonologist. The PCG was asked as to the last time the patient took the medication. The PCG replied, a month ago. The PCG also reported the patient was not taking Montelukast 10 mg one tablet PO QD. On 1/8/25 at 1448, the findings were shared with the CHHA . On 1/14/25 at 1239 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The Medication Profile for the certification period from 1/3/25 to 3/3/25, showed the patient medication list included the new and old medications. The medications included carbidopa 25 mg levodopa 100 mg (anti- Parkinson) tablet two tablets PO four times a day, tramadol (opioid) 50 mg tablet one tablet Q8H PRN for severe pain related to Parkinson’s, Zofran (anti -emetic) 4 mg tablet one tablet Q6H PRN for nausea, Colace (laxative) 100 mg capsule one capsule PO QD and melatonin (supplement) 10 mg one table PO QHS and triamcinolone acetonide (topical corticosteroids) 0.1 mg topical cream apply to affected area topically BID. A joint home visit with PTA was conducted on 1/9/25 at 0945 hours, to Patient 5’s home. Review of the patient’s medications with the PCG and the PTA showed the patient medication profile showed the following list: The list of the new medications included the following: -Flomax (selective alpha adrenergic blocking agent) 0.4 mg one capsule one capsule PO QD, -Cyanocobalamin -Vitamin B 12 ER (supplement) 1000 mcg tablet one tablet PO QD, -Multivitamin with minerals (supplement) one tablet PO QD, -Propranolol (beta adrenergic blocking agents) 10 mg one tablet PO BID. Hold for SBP less than 110 or Pulse rate less than 60 and -Vitamin D3 (supplement) 50 mcg (2,000 unit) one tablet PO QD. However, these new medications were not listed on the patient medication list in the facility. In addition, the medication profile showed the list of the old medications. The medications included the following: -lisinopril (antihypertensive) 10 mg one tablet PO QD, -albuterol sulfate HFA (bronchodilators) 90 mcg/actuation aerosol inhaler 2 puffs into lungs every 4 hours PRN for shortness of breath, -sertraline (anti- depressant) 25 mg tablet one tablet PO QHS and -Ativan (anti-anxiety) 1 mg one tablet PO QHS. However, these list of old medications were not listed on the patients medication list in the facility. On 1/9/25 at 1053 hours, an interview and concurrent clinical record review was conducted with the ALF Clinical Director and the PTA. The ALF Clinical Director was asked for the list of the patient medication profile. The ALF Clinical Director provided the current medication list. They verified the HHA medication profile does not match with the facility’s current list. The PTA was informed and acknowledged the finding. On 1/14/25 at 1117 hours, the findings were shared with the DPCS.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for three of seven sampled patients (Patients 1, 3, and 5), creating the increased risk of not addressing the care needs for these patients. Findings: 1.Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. a. Review of the Recertification OASIS dated 3/29/24, showed the RN had performed a comprehensive assessment. The assessment included a section of Wound/Lesion which showed the patient had an unstageable pressure injury to the left heel measuring 1.5 cm (length) x1.5 cm (width) and without odor or drainage. However, the wound assessment was incomplete as part of the comprehensive assessment. b. Review of the Discharge OASIS dated 4/4/24, showed the RN had performed a comprehensive assessment. The assessment included a section of Wound/Lesion which showed the patient had an unstageable pressure injury to the left heel measuring 1.5 cm (length) x1.5 cm (width), no odor but with small thick serosanguinous drainage. However, the wound assessment was incomplete as part of the comprehensive assessment. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. Cross reference to G984. 2. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the certification periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The assessment included a section for the patient’s height and weight. However, the section for height and weight were left blank. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the certification periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. Review of the Recertification OASIS dated 1/2/25, showed the RN had performed the comprehensive assessment. The assessment included the administrative information, COVID-19 screening, emergency preparedness, emergency contact information, functional status and musculoskeletal status. However, the multiple sections in the comprehensive assessments were left blank. On 1/10/25 at 1400 hours, an interview and concurrent clinical record review was conducted with the HR Manager. The HR Manager was asked to provide a copy of the recertification assessment. The HR Manager replied, the assessment was not completed. On 1/14/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked as to the timeline for the completion of the recertification assessment. The DPCS replied within 48 hours from the date of the visit. The DPCS 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 POCs included specific information related to medications, nutritional requirement, DME and supplies for four of seven sampled patients (Patients 4, 5, 7, and 8) creating the risk of not addressing the care needs for these patients. 3. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. * However, the POC failed to include DME/supplies and nutritional requirements. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 4. Review of Patient 7’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The POC, for the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25, cited SN visits 2W2 and 1W7 to perform comprehensive observation and assessment of all body. The POC included the following pain medications: acetaminophen (analgesic) 325 mg two tablets PO Q six hours for pain, diclofenac sodium (non-steroidal anti-inflammatory drug) gel 1% apply 4 gm topically Q six hours PRN for pain, and Percocet (opioid analgesic) 5-325 mg one tablet PO Q four hours PRN for pain. * However, there was no documented evidence which pain medication was to be given first. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 8’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed SN to perform and assess vital signs to include oxygen saturation, comprehensive observation and assessment of all body systems with emphasis to include respiratory every visit. POC includes an instruction to keep oxygen away from any open flame. However, the POC did not include specific instructions as to the level of oxygen the patient can use to address respiratory issues. In addition, the POC failed to include the DME and supplies as the section was left blank. Moreover, the POC also includes an instruction related to managing hyperlipidemia. However, the POC failed to include the patient nutritional requirement as the section was left blank. On 1/14/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis to include integumentary every visit. The POC includes the list of DME and supplies. The supplies included Betamethasone cream. Review of the SN notes on the following dates showed: -on 10/15/24 under the section of narrative notes, showed the SN had applied Betamethasone cream on the right arm. -on 11/8/24 under the section of narrative notes, showed the SN had applied Betamethasone cream on the arm. -on 11/14/24 under the section of narrative notes, showed the SN had applied Betamethasone 0.005 % cream to the affected area BID for itching. -on 11/21/24 under the section of narrative notes, showed the SN had applied Betamethasone cream on the affected area for itchiness. However, the POC failed to include specific instructions for the use of betamethasone cream. On 1/14/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC, for the certification period from 1/3/25 to 3/3/25 cited SN visits 1W9. The POC showed SN to continue to monitor, observe vital signs, neurological status, musculoskeletal status, cardiopulmonary/respiratory, circulatory status and pain level/comfort. However, the POC did not include nutritional requirement, DME and supplies as the sections were left blank. On 1/14/25 at 1110 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the treatment was provided only as ordered by the patient’s physician for three of the seven sampled patients (Patients 1, 3 and 6), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1.Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 1/30/24 to 3/29/24, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis to include integumentary system every visit. Review of the SN notes dated 2/9/24, on the section of narrative notes, showed the patient was assessed to have stage 1 pressure injury to the left heel. The SN performed wound treatment with calmoseptine (moisture barrier) and foam dressing. However, review of the closed clinical record failed to show a physician’s order for the wound treatment. In addition, review of the SN visit notes dated 2/16, 2/21, 2/28 and 3/9/24, on the section of wound type, showed the patient was assessed to have a stage 2 pressure injury. Further review of the SN notes, on the section of the narrative, showed the location of the pressure injury was to the left heel. The SN had performed wound dressing and treatment. The treatment includes clean with normal saline, pat dry and applied xeroform (petrolatum-based fine mesh gauze containing 3% bismuth tribromophenate), change dressing daily or as needed. However, review of the closed clinical record failed to show documented evidence of a physician’s order for the treatment of the patient’s stage 2 pressure injury to the left heel. Cross reference to G602 On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 8’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis on respiratory every visit. Review of the SN visit note dated 12/12/24, showed the SN had performed respiratory system assessment. The patient was on oxygen at 3 liters via nasal cannula and was assessed to have dry cough; with wheeze and SOB on moderate exertion of less than 20 feet. Further review of the SN visit notes dated 12/20, 12/23/24 and 1/4/25, showed the patient was on oxygen at 3 liters via nasal cannula and was assessed to have dry cough and with wheeze. However, review of the clinical record failed to show documented evidence of a physician’s order for the use of oxygen at 3 liters via nasal cannula. On 1/14/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if they needed to have a physician’s order for the use of oxygen. The DPCS replied yes. The DPCS was also asked if there was an order for the oxygen use. The DPCS replied it was not on the plan of care or supplemental order. The DPCS was informed and acknowledged the findings. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis to include respiratory and integumentary every visit. The POC included the list of DME and supplies. The list included oxygen concentrator. Review of the SN visit notes dated 10/15, 10/24, 10/30, 11/8, 11/14, 11/21, and 11/29/24, showed the SN had performed respiratory system assessment. The patient was on oxygen at 3 liters via nasal cannula and was assessed to have dry cough and with wheeze. However, review of the clinical record failed to show documented evidence of a physician’s order for the use of oxygen at 3 liters via nasal cannula. On 1/14/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 3. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the certification periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC, for the certification period from 11/10/24 to 1/8/25, cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. a. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment, on the section of wound care, showed the patient was identified to have a blister on the right buttock with the following treatment: cleansed with normal saline, pat dry, and apply calmoseptine (moisture barrier). Further review of the comprehensive assessment showed the blister on the right buttocks measured 1.5 cm (length) x 1.5 cm (width) with the following treatment: cleansed with normal saline, pat dry, and covered with Mepilex (a foam dressing that absorbs exudate and maintains a moist wound environment) dressing. However, review of the clinical record failed to show documented evidence of a physician’s order for wound treatment to the patient’s right buttock blister. b. Review of the SN notes dated 12/19 and 12/26/24. on the section of narrative, showed the SN had applied diclofenac (nonsteroidal anti-inflammatory drug) gel to the patient’s bilateral knees to relived pain. However, review of the clinical record failed to show documented evidence of the physician’s order for the use of diclofenac gel for pain. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was a physician’s order for wound treatment and diclofenac gel. The DPCS replied there was no physician’s order. The DPCS was informed and acknowledged the findings.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on interview and clinical record review, the agency failed to revise and update the POC for three of seven sampled patients (Patients 3, 4, and 8), creating the risk for not providing the necessary care and services to meet the care needs for these patients. 3. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems. The PT note dated 11/20/24, showed the PT conducted a visit. The PT note dated 11/25/24, showed the patient was discharged. * However, there was no documented evidence the POC during the certification period from 11/20/24 to 1/18/25, was revised to include PT services. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 8’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 12/6/24, showed the patient was assessed to have a dermatitis to the bilateral arms However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the assessment and treatment dermatitis should be address on the POC. The DPCS replied, it’s not and should have been address on the POC. The DPCS was informed and acknowledged the finding. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 10/9/24, showed the patient was assessed to have a dermatitis to the bilateral arms However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25 cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment on the section of wound care showed the patient was identified to have a blister on the right buttock. Cleansed with NS, pat dry, apply Calmoseptine. Further review of the comprehensive assessment showed the blister on the right buttocks measures 1.5 x 1.5 cm. Cleansed with NS, pat dry and covered by Mepilex dressing. However, the RN failed to update/ revised the POC to reflect the wound assessment and treatment for the identified blister on the right buttock. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the wound assessment and treatment needed to be included in the POC. The DPCS replied, it should be. The DPCS was informed and acknowledged the findings. - Cross ref. G-580 Findings: 1.Review of Patient 8’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. a. The POC, for the certification period from 12/10/24 to 2/7/25, cited SN visits 1W9. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 12/6/24, showed the patient was assessed to have a dermatitis to the bilateral arms. However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1150 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the assessment and treatment dermatitis should be address on the POC. The DPCS replied, it’s not and should have been address on the POC. The DPCS was informed and acknowledged the finding. b. The POC, for the certification period from 10/11/24 to 12/9/24, cited SN visits 1W8. The POC showed the other pertinent diagnosis includes dermatitis, unspecified. Review of the Recertification OASIS dated 10/9/24, showed the patient was assessed to have a dermatitis to the bilateral arms However, review of the POC failed to include specific interventions to address the patients dermatitis to the bilateral arms. On 1/4/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25 cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. Review of the Recertification OASIS dated 11/5/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment on the section of wound care showed the patient was identified to have a blister on the right buttock. Cleansed with NS, pat dry, apply Calmoseptine. Further review of the comprehensive assessment showed the blister on the right buttocks measures 1.5 x 1.5 cm. Cleansed with NS, pat dry and covered by Mepilex dressing. However, the RN failed to update/ revised the POC to reflect the wound assessment and treatment for the identified blister on the right buttock. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the wound assessment and treatment needed to be included in the POC. The DPCS replied, it should be. The DPCS was informed and acknowledged the findings. - Cross ref. G-580 3. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems. The PT note dated 11/20/24, showed the PT conducted a visit. The PT note dated 11/25/24, showed the patient was discharged. * However, there was no documented evidence the POC during the certification period from 11/20/24 to 1/18/25, was revised to include PT services. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“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 four of seven sampled patients (Patients 1, 3, 5, and 8), creating the risk of not providing necessary care and services to these patients. Findings: The agency’s P&P titled Coordination of Patient Care revised 3/2019 showed the agency must assure communication with all physicians involved in the plan of care. Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. 1. Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. Review of the SN visit notes dated 2/16, 2/21, 2/28, and 3/9/24, on the section of wound type, showed the patient was assessed to have a stage 2 pressure injury. Further review of the SN notes, on the section of the narrative, showed the location of the pressure injury was on the left heel. The SN had performed wound dressing and treatment. However, review of the closed clinical record failed to show documented evidence the physician was notified of the patient’s stage 2 pressure injury. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 8’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 2/14/24. The patient was certified for home health services during the certification periods from 10/11/24 to 12/9/24 and 12/10/24 to 2/7/25. The POC, for the certification period from 10/11/24 to 12/9/24, cited PT evaluation and treatment. The PT visits were cited 2W3. Review of the PT Clinical notes dated 10/30/24, showed a PT discharge. Review of the PT Communication Notes dated 10/30/24, showed a summary of care provided, physician’s order to discharge from PT and to follow up with physician, and the staff name, signature and date. However, the discharge order did not include the physician’s name, signature and date. On 1/14/25 at 1206 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if they needed to notify the patient’s physician of the PT discharge. The DPCS replied there was no notification. The DPCS was also asked if they needed to get a discharge order. The DPCS reviewed the clinical record and replied yes, but it was not signed. The DPCS was informed and acknowledged the findings. 3. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25, cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all the body systems. The POC also included to assess the pain, implement pain relief measures, evaluate its effectiveness every visit, and notify the physician for pain greater than 7 on a pain scale of 0 to 10 (0= no pain and 10 = worst pain), interfering with movement not relieved by pain medication/rest. Review of the SN notes on the following dates showed the patient was assessed to have pain using the pain scale of 0 to 10, zero meaning no pain and 10 meaning worst pain): -On 11/14/24 - 6/10, -On 11/21, 11/30, and 12/7/24 - 7/10, -On 12/12/24 - 9/10, -On12/19/24 - 8/10 and -On 12/26/24- 10/10. The pain was located at the bilateral knees described as achy and intermittent. The treatment was rest and gel. However, review of the clinical record failed to show documented evidence the patient’s complaints of pain greater than 7 on a pain scale of 0 to 10 was communicated to the patient’s physician. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. Cross ref. G-710 4. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for home health services during the certification periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The Recertification OASIS dated 11/2/24, showed the patient was requesting a continuation for PT. The patient was assessed to have generalized weakness. However, review of the clinical record failed to show documented evidence the request for PT services was coordinated with the physician. Further, review of the SN visit notes dated 11/5, 11/15, 11/22, 11/25, 12/5, 12/12, 12/19, and 12/23/24, showed the SN had performed the motor/musculoskeletal system assessment. The patient was assessed to have a decreased in mobility and had weakness with assistive device. However, review of the clinical record failed to show documented evidence of the physician was notified of the decrease mobility as identified on the assessment. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the need for PT was coordinated with the physician. The DPCS replied there was no documentation at this time, and she cannot find the notes in the system. The DPCS was informed and acknowledged the findings.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services provided to the patient was coordinated for one of seven sampled patients (Patient 4), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all the body systems. The Communication Note dated 12/6/24, showed the LVN reported the patient was complaining of difficulty in sleeping. Documentation showed the physician was notified. However, there was no documented evidence the HHA had coordinated/followed up what the physician’s response was after the physician was notified of patient’s difficulty in sleeping. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide a written instructions outlining the visit schedule for one of seven sampled patients (Patients 4). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all the body systems. A joint home visit with RN 1 was conducted on 1/9/25 at 1000 hours, to Patient 4’s home. Review of the patient’s home folder was conducted with RN 1. However, there was no documented evidence of written instructions outlining the SN visit schedules. On 1/14/25 at 1120 hours, an interview and concurrent clinical record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the clinical managers contact information were provided to three of the seven sampled patients (Patients 3, 4 and 5), creating the risk of substandard care provided to these patients as the contact information were not available. 3. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. A joint home visit with RN 1 was conducted on 1/9/25 at 1000 hours, to Patient 4’s home. Review of the patient’s home folder was conducted with RN 1. * However, the contact information of the agency’s clinical manager was not available in the patients home folder. On 1/14/25 at 1120 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. The agency’s P&P titled Coordination of Patient Care revised 3/19, showed the agency will coordinate care with the patient by providing a copy of written instructions outlining the name and contact information of the agency’s Director of Clinical Services. 1. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for hospice services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC, for the certification period from 11/10/24 to 1/8/25, cited CHHA 1W4 and reassess. A joint home visit with CHHA was conducted on 1/8/25 at 1330 hours, to Patient 3’s home. Review of the agency’s admission packet was conducted with the CHHA and the PCG. The agency’s admission packet showed the names of the agency’s visiting staff. However, review of the patient’s admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA’s clinical manager. On 1/8/25 at 1448 hours, an interview and concurrent document review was conducted with the CHHA and the PCG. They were asked if the contact information of the agency’s clinical manager was available in the home folder. The CHHA reviewed the home folder and replied no, I didn’t see it. On 1/14/25 at 1239 hours, the DPCS was informed of the finding. 2. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. The POC, for the certification period from 1/3/25 to 3/3/25, cited PT evaluation and treatment. A joint home visit with PTA was conducted on 1/9/25 at 0945 hours, to Patient 5’s home. Review of the agency’s admission packet was conducted with the PTA. The agency’s admission packet showed the names of the agency’s visiting staff. However, review of the patient’s admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA’s clinical manager. On 1/9/25 at 1039 hours, an interview and concurrent document review was conducted with the PTA and the PCG. They were asked if the contact information of the agency’s clinical manager was available in the home folder. The PTA reviewed the home folder and replied no, I don’t see it here. On 1/14/25 at 1117 hours, the DPCS was informed of the finding.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patients received care and services as per the written plan of care for four of the seven sampled patients (Patients 1, 3, 4, and 7). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. 3. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. The SN notes dated 11/21, 11/27, 12/4, 12/13, and 12/27/24, showed under the patient’s cardiovascular assessment showed a box was marked as “Other.” * However, there was no documented evidence on what was the SN’s cardiovascular assessment for the patient. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 4. Review of Patient 7’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The POC, for the certification period from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25, cited SN visits 2W2 and 1W7. The POC included the following: -SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. -SN to instruct caregiver on “foley” catheter care and for SN to perform catheter change every 30 days or as needed for leakage or dislodgement. a. The SN note dated 11/29/24, showed no documented evidence the assessment for EENT, gastrointestinal, and genitourinary was completed. b. The start of care assessment dated 10/26/24, showed the patient’s last urinary catheter change was on 10/26/24. * However, there was no documented evidence the SN performed catheter change for the month of November, which was more than 30 days as per the POC. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1a. Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 3/20/24 to 5/28/24, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, digestive status and to check oxygen saturation every visit. The POC also includes the patient nutritional requirement was low sodium, no concentrated sweets. * Review of the SN notes dated 4/3, 4/8 and 4/24/24 showed the SN assessed the patients’ diet was regular. However, the diet order was low sodium, no concentrated sweets. * Review of the SN notes dated 4/3, 4/8 and 4/24/24, showed the SN had performed gastrointestinal assessment. However, the SN failed to check the patients’ last bowel movement as the section was left blank. * Review of the SN notes dated 4/24/24, showed the SN had performed respiratory assessment. However, the SN failed to check the patients’ oxygen saturation level as section was left blank. On 1/14/25 at 1208 hours an interview and concurrent closed medical record review was conducted with the DPCS. The DPCS was asked if the patient diet was followed as ordered. The DPCS reviewed the SN visit notes and replied no. The DPCS was also asked if the SN needed to check the patients oxygen saturation and the last bowel movement every visit. The DPCS replied, yes, should be check but none was documented. The DPCS was further asked if the POC was followed. The DPCS replied, not followed. The DPCS was informed and acknowledged the findings. b. The POC, for the certification period from 1/30/24 to 3/29/24, cited SN visits 1W9. The POC showed SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine and integumentary every visit. The POC showed to instruct patient/caregiver on dietary compliance on low sodium, no concentrated sweets. * Review of the SN notes dated 2/9, 2/16, 2/21, 2/28 and 3/21/24, showed the SN had assessed the patients diet. The diet was documented as regular. However, the order was for low sodium, no concentrated sweets. In addition, review of the SN notes dated 3/9 and 311/24, failed to show the SN had assessed the patients diet as the section was left blank. * Review of the SN notes dated 2/9, on the section of Wound Type, showed the patient was assessed to have stage 1 pressure injury. The location of the pressure injury was to the left heel as documented on the narrative notes. However, the SN failed to assessed the pressure injury stage 1 as ordered on the POC. In addition, review of the SN notes dated 2/16, 2/21, 2/28 and 3/9/24 showed the patient was assessed to have a stage 2 pressure injury. The location of the pressure injury was to the left heel as documented on the narrative notes. However, the SN failed to performed a complete wound assessment for the patients pressure injury stage 2 as ordered on the POC. Cross ref. G-984 * Review of the SN notes dated 2/28/24, showed the SN had performed body system assessment. However, the the SN failed to assessed the patients cardiovascular, respiratory, EENT and Motor/musculoskeletal system as ordered in the POC. On 1/14/25 at 1208 hours an interview and concurrent closed medical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2a. Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for home health services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC for the certification period from 11/10/24 to 1/8/25 cited SN visits 1W9. The POC showed SN to perform comprehensive assessment of all body systems. The POC also includes to assess pain scale and implement pain relief measures and evaluate its effectiveness every visit and notify MD for pain scale greater than 7/10, interfering with movement not relieved by pain medication/rest. Review of the SN notes on the following dates showed the patient was assessed to have pain: -On 12/12/24 - 9/10, -On12/19 - 8/10 and -On 12/26- 10/10. The pain was located at the bilateral described as achy and intermittent. The documented treatment was rest and gel. However, review of the clinical record failed to show documented evidenced of the physician was notified of the patients pain as ordered in the POC. On 1/14/25 at 1243 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. The POC for the certification period from 9/11/24 to 11/9/24, cited PT evaluation and treatment. Review of Physicians Order dated 9/13/24 showed a visit frequency for 1W1, 2W3,1W1. Review of the PT visits on Week 2 (9/15/24 to 9/21/24) showed the PT visit the patient on 9/17/24 However, the PT visited the patient one time instead of two times as ordered by the physician. In addition, review of the PT visit notes on Week 5 (10/6 to 10/12/24), showed the PT visited the patient on 10/7/23. Review of the Physicians Order dated 10/11/24, showed an order for a change in PT visit frequency. The order was cited for 2W2, 1W1. However, there was no documented evidenced of the PT visited the patient on 10/12/24 for as ordered by the physician. c. Review of the Admission Order dated 9/11/24, showed the diet order was no added salt, high fiber, high protein, low cholesterol and low fat. However, review of the POC for the certification period 9/11/24 to 11/9/24, showed the diet order was regular which was inconsistent with the physicians order. On 1/14/25 at 1227 hours, an interview and concurrent clinical record review was conducted with the LVN Care Coordinator, HR Manager and the Administrator. They were informed and acknowledged the findings.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and or caregiver was provided an education related to disease process and management of diabetes, medication and Port-a catheter care as per the plan of care for two of the seven sampled patients (Patients1 and 4), creating the risk of not providing the necessary care and services these patients. 3. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The recertification reassessment dated 11/16/24, showed not applicable under infusion assessment. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 (one time per week for nine weeks) to perform comprehensive observation and assessment and all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. The SN note dated 12/13/24, showed during the home health visit the patient was educated on the chemotherapy regimen with 5-fluorouracil (medication to treat cancer) and care of the port- a catheter. There was no documented evidence the POC included education on the care of the port-a catheter and the patient’s medication included 5-fluorouracil. * However, the POC did not include education related to port-a-catheter and 5-fluorouracil. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1.Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 3/20/24 to 5/28/24, cited SN visits 1W9. The POC includes SN to teach disease processes and management, preventive measures, signs and symptoms of complication/exacerbations with emphasis on Type 2 DM. SN to instruct on managing hypoglycemia through meals, help prevent hypoglycemic reactions and maintain overall blood glucose control. Review of the SN visit notes dated 4/3, 4/8, 4/17 and 4/24/24 on the section of Skilled Teaching/ Instructions showed a check mark on skilled observation and assessment, teach disease process related to and teach prevention of disease exacerbation and hospitalization. However, on the section of teach diabetic care, hypoglycemia and hyperglycemia was left blank. On 1/14/25 at 1208 hours an interview and concurrent closed medical record review was conducted with the DPCS. The DPCS was asked if diabetic teaching or instructions was provided to the patient as ordered in the POC. The DPCS reviewed the SN visit notes and replied no. The DPCS was informed and acknowledged the findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s skilled professionals prepared accurate clinical notes for four of 7 sampled patients (Patients 1, 4, 5, and 7), creating the increased risk of substandard healthcare outcomes to these patients. 3. The P&P titled Timely Submission of Documents revised date 2017, showed itineraries will all visit reports attached must be submitted the next scheduled work day, not exceeding three business days. All patient visit reports from contract personnel must be submitted within three business days from the date of the visit. Review of Patient 4’s clinical record was initiated on 1/13/25. The clinical record showed the SOC was 3/25/24. The patient was certified for home health services during the certification period from 11/20/24 to 1/18/25. The POC, for the certification period from 11/20/24 to 1/18/25, cited SN visits 1W9 to perform comprehensive observation and assessment and all body systems. The electronic clinical record showed the SN conducted a visit on 1/1/24. * However, there was no documented evidence the SN completed the note as of 1/13/24. On 1/14/25 at 1115 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 4. Review of Patient 7’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The POC, for the certification period from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25, cited SN visits 2W2 and 1W7. The POC included SN to perform comprehensive observation and assessment of all body systems with emphasis on cardiovascular, respiratory, musculoskeletal, endocrine, integumentary, urinary, digestive, and mental/emotional status. The POC included SN to instruct caregiver on “foley” catheter care and for SN to perform catheter change every 30 days or as needed for leakage or dislodgement. a. The start of care assessment dated 10/29/24, showed under the wound section the patient had Stage 2 left heel pressure injury. Documentation showed under narrative section of the form showed the patient had left heel diabetic ulcer. The Wound Care Work Sheet dated 10/29/24, showed the patient had Stage 2 left heel pressure injury. * However, the type of wound documented was not consistent on 10/29/24. b. The SN note dated 12/3, 12/7, 12/10, 12/17, 12/21, and 12/31/24, showed “See Wound sheet assessment and treatment.” However, there was no documented evidence the SN completed the wound sheet assessment and treatment. c. The start of care assessment dated 10/26/24, showed the patient’s last urinary catheter change was on 10/26/24. The SN note dated 12/31/24, showed last catheter change was performed on 12/31/24. Documentation showed the patient has “Foley catheter which is due for changing.” Documentation showed SN “cleaned the patient as needed Foley changed/reinforced infection control.” The SN note dated 1/1/25, showed last catheter change was performed on 1/1/25. * However, there was no documented evidence indication for the catheter change on 1/1/25. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1a. Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. The POC, for the certification period from 3/20/24 to 5/28/24, cited SN visits 1W9. The POC showed SN to performed comprehensive observation and assessment of all body systems. The POC showed SN to teach disease processes and management, preventive measures, signs and symptoms of complications/exacerbations with emphasis on Type 2 DM. The POC also include SN to check VS and oxygen saturation every visit and notify MD if less than 90%. * Review of the SN visit notes dated 4/3, 4/8, 4/17, and 4/24/24 showed the SN had performed body system assessment. The body system assessment includes endocrine. The endocrine assessment showed a check marked on the section of no problem. However, the assessment was inconsistent with the POC. * Review of the SN notes dated 4/3 and 4/8/24 on the section of the respiratory assessment, showed the lung sounds were clear. In addition, on the section of Additional SN notes notes showed the patient was not in distress. However, the SN documented the patients oxygen saturation was 67% which was inaccurate. * Review of the SN visit notes dated 4/3, 4/8, 4/17 and 4/24/24 on the section of additional SN notes showed the patient was assessed to have wound on the left heel. Wound treatment was provided. Review of the integumentary system assessment included the wound type. The section for wound type showed a check marked on “see wound assessment and treatment”. However, review of the clinical record failed to show documented evidenced of the wound assessment and treatment form as checked on the assessment. b. The POC, for the certification period from 1/30/24 to 3/29/24, cited SN visits 1W9. The POC showed SN to performed comprehensive observation and assessment of all body systems. * Review of SN notes dated 2/16/24 on the section of narrative notes, showed the SN had provided wound care to the patients stage 2 pressure injury to the left heel. Clean with normal “sailing”, “Sarah form” and cover it with nonadherent dressing. Instructed the facility caregivers on putting “health” protector. * Review of the SN notes dated 2/9, 2/16, 2/21, 2/28, 3/9 and 3/21/24, showed the SN had performed integumentary assessment. The assessment included wound type. on the section for wound type showed a check mark on “see wound assessment and treatment form”. However, review of the clinical record failed to show documented evidenced of the wound assessment and treatment form as checked on the assessment. * The POC showed SN to teach disease processes and management, preventive measures, signs and symptoms of complications/exacerbations to include type 2 diabetes mellitus. Review of the SN visit notes dated 2/9, 2/16, 2/28, 3/9, 3/11 and 3/21/24 showed the SN had performed body system assessment to include endocrine. However, the endocrine section for no problem had a check mark which was inaccurate. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 1/10/25. The clinical record showed the SOC was 5/8/24. The patient was certified for hospice services during the periods from 11/4/24 to 1/2/25 and 1/3/25 to 3/3/25. Review of the SOC OASIS dated 5/8/24, showed the patients primary language was Vietnamese. Review of the face sheet, showed the patients primary language was Vietnamese. The patients secondary language was English. However, the Recertification OASIS dated 11/2/24, showed the patient’s primary language was English instead of Vietnamese. On 1/14/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked as to the patients primary language. The DPCS replied. The patients primary language was English and not Vietnamese. They overlook the Vietnamese documentation. The DPCS was informed and acknowledged the finding.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure care and services were provided in accordance with the care plan for one of seven sampled patients (Patient 3), creating the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 3’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 9/11/24. The patient was certified for HHA services during the periods from 9/11/24 to 11/9/24 and 11/10/24 to 1/8/25. The POC, for the certification period from 11/10/24 to 1/8/25, cited CHHA 1W4 and reassess. The POC showed the CHHA to continue providing basic personal care, such as bathing, dressing and grooming. Assisting the patient in ambulating and transferring. Review of the Home Health Aide Care Plan for the certification period from 11/10/24 to 1/8/25, showed the assignment for the CHHA every visit. The assignment included for personal care, bathing, assisting with ambulation, mobility and light housekeeping in the bathroom. The assignment also includes to check the vital signs - blood pressure, temperature, pulse, respiration and pain scale every visit. A joint home visit with CHHA was conducted on 1/8/25 at 1330 hours, to Patient 3’s home. The CHHA provided the basic personal care as ordered in the POC. However, the CHHA failed to check the patient’s vital signs as ordered on the care plan. On 1/8/25 at 1448 hours. the CHHA was asked if she needed to check the patient vital signs. The CHHA replied, forgot to check it this time. The CHHA was informed and acknowledged the findings. On 1/14/25 at 1239 hours, the DPCS was informed of 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 document review, the agency’s Administrator failed to be responsible for the day-to-day operations related to the written agreements with Contractors 1, 2, 3, 4, 5, and 6. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. d. Review of the written agreements between the hospice and Contractor 6 was initiated on 1/14/25. The written agreements with Contractor 1 did not include the roles and responsibilities of the program and the contracted providers in the coordination and evaluation of care and services provided. On 1/14/25 at 1159 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. a. Review of the written agreement between the agency and contractor 1 was conducted on 1/14/25. The written agreement provided RN and PT services. However, the written agreement failed to include the role of the agency and the contractor in patient admission process, patient assessment and scheduling of visits or hours. In addition, the written agreement failed to include the procedures for determining charges for PT services. b. Review of the written agreement between the agency and the Contractor 2, showed the nature and scope of services to be provided was for RN. However, the contract was for LVN. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment, scheduling of visit hours and discharge planning. c. Review of the written agreement between the agency and the Contractor 3, 4 and 5 showed the written agreement provided RN services. However, the written agreement failed to include the roles of the agency and the contractor in patient admission process, patient assessment and scheduling of visits or hours. On 1/14/25 at 1059 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS reviewed the written agreement and acknowledged the findings.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency’s Administrator failed to be responsible for the day-to-day operations as the agency’s P&P related to wound assessments was completed in accordance with the agency’s P&P for two of 7 sampled patients (Patients 1 and 7). In addition, two contracted employee’s (LVN 2 and RN 2) did not complete the orientation program. The performance evaluation and skills competency were not completed by LVN 2. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. b. Review of Patient 7’s clinical record was initiated on 1/9/25. The clinical record showed the SOC was 10/29/24. The patient was certified for home health services during the certification periods from 10/29/24 to 12/27/24 and 12/28/24 to 2/25/25. The start of care assessment dated 10/29/24, showed the patient had Stage 2 left heel pressure injury. Documentation showed the size was 4 cm (length) X 5 cm (width). However, there was no documented evidence weekly wound assessment was conducted on Week 2 (11/2/24 to 11/9/24), Week 3 (11/10/24 to 11/16/24), Week 4 (11/17/24 to 11/23/24), Week 5 (11/24/24 to 11/30/24), Week 6 (12/1/24 to 12/7/24), Week 7 (12/8/24 to 12/14/24), and Week 8 (12/15/24 to 12/21/24) as per the agency’s P&P. On 1/14/25 at 1130 hours, an interview and concurrent record review was conducted with the Administrator and LVN Care Coordinator. They were informed and acknowledged the findings. 1. The agency’s P&P titled Administrator revised 3/2018, showed the Administrator is responsible for the agency’s functions and all day - to -day operations of the agency. The Administrator of the agency has the responsibilities to include complying with applicable laws and regulations. Review of the agency’s P&P titled Personnel Records revised 9/2019, showed personnel files will be established and maintained for all staff. The personnel record or personnel information for an employee will include but not limited to job description, reviewed and signed by employee. Review of the agency’s P&P titled Employee Orientation revised 9/2019, showed the orientation checklist will be used to document orientation for all staff, including contract staff. Orientation for each employee will minimally included confidentiality and privacy of protected health information and emergency plan. Review of the agency’s P&P titled Staff Competency Program revised 3/2018, showed the agency will provide for initial and ongoing competency assessments for all patient care staff by qualified individuals. The procedure includes the patient care staff will be competency assessed for each new employee (including contract employees) during orientation. The competency evaluation checklist will be completed and retained in the employee’s record. Review of the personnel file was conducted on 1/13/25 for the following contracted staff: -LVN 2’s personnel file showed the hiring date was 10/18/23. However, there was no documented evidence of the orientation, performance evaluation and skills competency were completed upon employment as per P&P. In addition, the file failed to include the employees signed job description as per P&P. Further review of the file failed to show documented evidenced of the training for confidentiality and privacy of protected health information and emergency plan was completed as part of the orientation as per P&P. -RN 2’s personnel file showed the hiring date was 6/28/22. However, there was no documented evidence of the orientation completed upon employment. In addition, the file failed to include the employees signed job description as per P&P. Further review of the file failed to show documented evidenced of the training for confidentiality and privacy of protected health information was completed upon orientation as per P&P. On 1/13/25 at 1425 hours, an interview and concurrent document review was conducted with the HR Manager. The HR Manager was informed and acknowledged the findings. 2. The agency’s P&P titled Assessment Of Wound/Pressure Ulcer undated showed home care should use a risk assessment tool to determine risk and plan accordingly. Wound assessment needs to be done by all clinicians during initial admission, on a weekly and as needed for new change of condition. The pressure ulcer assessment guide showed in assessing the wound/pressure ulcer, the following parameters should be address consistently: site, stage of ulcer, and size of ulcer (include length, width and depth) presence of tunneling or undermining, presence of necrotic tissue (slough or eschar), drainage amount, color, odor, pain and condition of surrounding tissue. a. Review of Patient 1’s closed clinical record was initiated on 1/7/25. The clinical record showed the SOC was 1/30/24. The patient was certified for home health services during the certification periods from 1/30/24 to 3/29/24 and 3/30/24 to 5/28/24. The patient was discharged from the agency on 4/24/24. *Review of the Recertification OASIS dated 3/29/24 on the section of Wound/Lesion showed the patient was assessed to have an unstageable pressure injury to the left heel measuring 1.5 x1.5 cm; odor and drainage - none. However, the wound assessment was incomplete as per P&P. *Review of the SN visit notes dated 4/3, 4/8, 4/17 and 4/24/24 on the section of additional SN notes showed the patient was assessed to have wound on the left heel. Wound treatment was provided. However, review of the clinical record failed to show documented evidenced of a completed wound assessment as per P&P. *Review of the Discharge OASIS dated 4/4/24 on the section of Wound/Lesion showed the patient was assessed to have an unstageable pressure injury to the left heel measuring 1.5 x1.5 cm; odor - none; and drainage - small; color - serosanguinous; consistency - thick However, the wound assessment was incomplete as per P&P. On 1/14/25 at 1208 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”