Hemet Home Health Care

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician’s verbal orders were signed and dated timely, within 20 days of order date for four of four patients reviewed (Patients 1, 2, 3, and 4). This failure resulted in verbal orders not authenticated and dated by the physician in accordance with the agency’s policy and procedure. In addition, this failure had the potential to result in incorrect verbally ordered medications and treatment for patients which could cause unnecessary care and services. Findings: On December 1, 2025, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of September 10, 2025, with diagnoses which included Intervertebral disc degeneration (age-related breakdown of spinal disc). Patient 1’s Plan of Care (POC) for the certification period of September 10, 2025, to November 8, 2025, was not signed and dated. The physician’s verbal orders in the POC were not signed and dated within 20 working days. On December 1, 2025, Patient 2’s record was reviewed. Patient 2 was admitted to the agency with the SOC date of June 6, 2025, with diagnoses which included hypertension (high blood pressure). Patient 2’s POC for the certification period of June 26, 2025, to August 24, 2025, was not signed and dated. The physician’s verbal orders in the POC were not signed and dated within 20 working days. Patient 2’s POC for the certification period of November 3, 2025, to January 1, 2026, was not signed and dated. The physician’s verbal orders in the POC were not signed and dated within 20 working days. On December 1, 2025, Patient’s 3’s record was reviewed. Patient 3 was admitted to the agency with the SOC date of May 5, 2025, with diagnoses which included displaced supracondylar fracture (a break in the lower arm just above the elbow, where the bone pieces have moved out of alignment). Patient 3’s POC for the certification period of May 5, 2025, to July 3, 2025, was not signed and dated. The physician’s verbal orders in the POC were not signed and dated within 20 working days. On December 1, 2025, Patient 4’s record was reviewed. Patient 4 was admitted to the agency with the SOC date of August 15, 2025, with diagnoses which included pressure ulcer (bedsore) of the sacral region (tail bone). Patient 4’s certification period of August 15, 2025, to October 13, 2025, was not signed and dated. The physician’s verbal orders in the POC were not signed and dated within 20 working days. Patient 4’s certification period of October 14, 2025, to December 12, 2025, was not signed and dated. The physician’s verbal orders in the POC were not signed and dated within 20 working days. During an interview on December 2, 2025, at 12:15 p.m., with the Registered Nurse (RN), she stated at the SOC assessment, a POC is determined and the physician is called to verify the POC. The POC contains the medications and treatment orders for the patient. The orders are considered telephone or verbal orders. The RN was not sure who is responsible for following up to ensure the POCs are signed by the physicians. During an interview on December 2, 2025, at 12:33 p.m., with the Director of Patient Care Services Nursing (DPCS), she stated the POCs are called to the physicians for verification, and a copy is sent to the physician for signature. The DPCS stated she was not responsible for following up on physician’s signatures. She stated it was assigned to the office staff. The DPCS stated she was aware the POCs should be signed by the physicians. A concurrent record review was conducted with the DPCS. She stated the POCs for Patients 1, 2, 3, and 4 were not signed within 20 working days. She stated the POCs should have been signed by the physicians within 20 working days. During an interview on December 2, 2025, at 1:05 p.m., with the Administrator (ADM), he stated the agency tried to get the physicians to sign the POCs within 20 working days as per the agency’s policy and procedure. He stated the POCs were mailed to the physicians, but the physicians failed to sign and return the POCs. He stated the physicians were not sending the signed POCs on time. The agency’s policy titled, “Plan of Care,” dated January 2025, indicated, “…A written plan of care for Home Health Agencies participating in Medicare and/or MediCal program shall be established for each patient whose care requires medical orders. A plan of care for patients requiring medical orders shall be…Approved and signed within 20 working days by the attending physician…””

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement emergency preparedness policies and procedures by failing to ensure: 1. The agency’s policy and procedure based on emergency preparedness must be reviewed and updated at least every two years (Refer to E-0004); 2. The agency’s risk assessment based on all hazards were identified and completed (Refer to E-0013); and 3. The agency’s training and testing were conducted in a full-scale exercise that is community based annually or facility-based functional exercise every two years (Refer to E-0036). The cumulative effect of this systemic failure resulted in the agency’s lack of preparation and knowledge on how to respond in an emergency disaster events and could potentially place the patients, patient’s families, care givers and staff in imminent danger.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on interview and record review the agency failed to develop, implement and maintain and effective, on-going, home health agency-wide, data driven quality assessment and performance improvement (QAPI) program. The agency’s lack of a QAPI program resulted in the failure of the agency to identify problems, implement solutions, and evaluate the effectiveness of the care provided by the agency. The cumulative effect of this system failure resulted in the Home Health Agency’s failure to ensure quality care and services were being provided in a safe an effective manner. Findings: On January 6, 2025, an unannounced visit was conducted at the agency for a recertification survey. At the time of the survey, the administrator (ADM) was out of the country. On January 8, 2025, at 4:45p.m., the Director for Patient Care Services (DPCS) was not able to provide documented evidence of a QAPI program which included the following: -Tracking of quality indicators, adverse patient events and other aspects of performance that would allow the Home Health Agency (HHA) to develop improvement measures; -Using data collected from quality indicators and other relevant data to monitor the effectiveness of services and quality of care to identify opportunities for improvement at a frequency approved by the governing body; -Documentation of the HHA’s improvement activities; -Documentation of performance improvement projects; and -Evidence the agency’s governing body assumed overall responsibility for the QAPI program and QAPI activities. On January 13, 2025, at 10:15 a.m., during a telephone interview with the ADM, he stated the agency did not have a QAPI program in place.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and maintain an emergency preparedness program that must be reviewed and updated at least every two years. This failure had the potential for the agency not to be able to respond accordingly in an emergency and could place the patients, patient’s family, and staff in danger. Findings: On January 9, 2025, at 10:25 a.m., during an interview with the Office Supervisor, (OS) she stated the agency had an emergency preparedness plan. She stated an evacuation plan was posted on the wall. She also stated the agency had an in-service on emergency preparedness that was conducted two months ago. The OS stated the agency did not conduct an emergency drill in the office or had participated in any community emergency drill. She stated the agency had not designated the person that would initiate the call to all the office staff in case of a disaster. She stated. “I guess that would be me.” On January 13, 2025, at 10:15 a.m., during a telephone interview with the Administrator (ADM), he stated the agency had an emergency plan and it was reviewed annually. He stated the Director for Patient Care Services (DPCS) and himself reviewed and updated the Emergency Preparedness Plan. The ADM stated he did not have a sign-in sheet during the annual review of the emergency preparedness plan. On January 13, 2025, at 10:30 a.m., during a telephone interview with Certified Home Health Aide (CHHA) 1, CHHA 1 stated she participated in an emergency preparedness in-service but did not participate in any drill. On January 13, 2025, at 11:40 a.m., during an interview with Licensed Vocational Nurse (LVN) 6, she stated the agency conducted in-service on earthquakes. She stated the agency did not conduct drills on emergency preparedness. On January 13, 2025, at 12 p.m., during a telephone interview with LVN 5, she stated she could not recall participating with the agency’s emergency preparedness in-service or drill. On January 13, 2025, at 12:15 p.m., during a telephone interview with LVN 1, she stated she had emergency preparedness training from the agency when she was hired in October 2021. She stated she did not participate in emergency drills with the agency. On January 13, 2025, at 4:35 p.m., during an interview with the DPCS, she stated the agency had an in-service on emergency preparedness in November 2024. The DPCS presented a sign-in sheet for an emergency preparedness in-service conducted on November 1, 2024. The DPCS was not able to provide the lesson plan for the in-service. She also stated the agency did not have an office drill for emergency preparedness and did not participate in a community-based drill. The facility’s policy and procedure titled, “Disaster Preparedness,” dated October 2024, indicated, “…Policy…To provide for the care and safety of (Name of Agency) employees, minimize agency disruption and maximize operations to ultimately provide the continuity of patient care…The Disaster Preparedness Plan is therefore divided in two plans…(1) is the on-site disaster plan providing for the care and safety of Agency employees and clients in the event of, but not limited to, fire and earthquake, and as needed in evacuation plan: (2) a clinical continuity of care plan…” The agency’s Emergency Preparedness Plan did not include all the required elements for Emergency Preparedness.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement an emergency preparedness program based on all hazards approach identified during the agency’s risk assessment. This failure had the potential for the agency not to be able to respond accordingly in an emergency that could place patients, patient’s family, and staff in danger. Findings: On January 13, 2025, at 10:15 a.m., during a telephone interview with the Administrator (ADM), he stated the agency had an emergency plan and it was reviewed annually. He stated the Director for Patient Care Services (DPCS) and himself reviewed and updated the Emergency Preparedness Plan. The ADM stated he did not have a sign-in sheet during the annual review of the emergency preparedness plan. He stated not all of the agency’s policy and procedures were revised, only portions the agency needed to change or revise, including the emergency preparedness plan. On January 13, 2025, at 4:35 p.m., during an interview with the DPCS, the DPCS was asked if the agency had a risk assessment for emergencies conducted annually. The DPCS responded “What is that?” The facility’s policy and procedure titled, “Disaster Preparedness,” dated October 2024, indicated, “…Policy…To provide for the care and safety of (Name of Agency) employees, minimize agency disruption and maximize operations to ultimately provide the continuity of patient care…The Disaster Preparedness Plan is therefore divided in two plans…(1) is the on-site disaster plan providing for the care and safety of Agency employees and clients in the event of, but not limited to, fire and earthquake, and as needed in evacuation plan: (2) a clinical continuity of care plan…” The agency was not able to provide documentation a risk assessment was conducted to develop an emergency preparedness program.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and maintain an emergency preparedness training and testing program. This failure had the potential for the agency not to be able to respond accordingly in an emergency and could place the patients, patient’s family, and staff in danger. Findings: On January 9, 2025, at 10:25 a.m., during an interview with the Office Supervisor, (OS) she stated the agency had an in-service on emergency preparedness that was conducted two months ago. The OS stated the agency did not conduct an emergency drill in the office or had participated in a community emergency drill. She stated the agency had not designated the person that would initiate the call to all the office staff in case of a disaster. She stated. “I guess that would be me.” On January 13, 2025, at 10:15 a.m., during a telephone interview with the Administrator (ADM), he stated the agency conducted an in-service for emergency preparedness last year. On January 13, 2025, at 10:30 a.m., during a telephone interview with Certified Home Health Aide (CHHA) 1, CHHA 1 stated she participated in emergency preparedness in-service but did not participate in any drill. On January 13, 2025, at 11:40 a.m., during an interview with Licensed Vocational Nurse (LVN) 6, she stated the agency conducted in-service on earthquakes. She stated the agency did not conduct drills on emergency preparedness. On January 13, 2025, at 12 p.m., during a telephone interview with LVN 5, she stated she could not recall participating with the agency’s emergency preparedness in-service or drill. On January 13, 2025, at 12:15 p.m., during a telephone interview with LVN 1, she stated she had emergency preparedness training from the agency when she was hired in October 2021. She stated she did not participate in emergency drills with the agency. On January 13, 2025, at 4:35 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated the agency had an in-service on emergency preparedness in November 2024. The DPCS presented a sign-in sheet for an emergency preparedness in-service conducted on November 1, 2024. The DPCS was not able to provide the lesson plan for the in-service. She also stated the agency did not have an office drill for emergency preparedness and did not participate in a community-based drill. The facility’s policy and procedure titled, “Disaster Preparedness,” dated October 2024, indicated, “…Policy…To provide for the care and safety of (Name of Agency) employees, minimize agency disruption and maximize operations to ultimately provide the continuity of patient care…The Disaster Preparedness Plan is therefore divided in two plans…(1) is the on-site disaster plan providing for the care and safety of Agency employees and clients in the event of, but not limited to, fire and earthquake, and as needed in evacuation plan: (2) a clinical continuity of care plan…” The agency was not able to provide documented evidence an emergency preparedness training and testing was implemented.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview, and record review, the agency failed to electronically submit the completed Outcome and Assessment Information Set (OASIS - a standardized set of data elements used by home health agencies to collect and report patient information, to track and monitor quality of home health, used to develop individualized care plans, identify areas for quality improvement, and measures the effectiveness of home health services.) to the Centers for Medicare and Medicaid Services (CMS) within 30 days of completing the assessment for five patients reviewed (Patients 18, 19, 20, 21, and 22). This failure had the potential to result in the delay of assessment, the development of patient’s plan of care, and delivery of necessary care and services needed to meet patient’s individualized quality of care. Findings: On January 8, 2025, at 2 p.m., a concurrent interview and record review was conducted with the agency’s billing coordinator (BC) related to the late submission of OASIS for the report period from October 1, 2024 to December 24, 2024. The BC stated there were five patients identified with the late submission of the OASIS as follows: 1. Patient 18 was admitted to the agency with start of care (SOC) date of July 1, 2023, with diagnosis which included psychosis (a mental disorder). The certification period from August 24, 2024 to October 22, 2024, indicated Patient 18 was hospitalized from August 27, 2024 to August 31, 2024. The resumption of care was September 4, 2024. The OASIS Resumption Of Care (ROC) assessment was completed on September 4, 2024. The BC stated the OASIS ROC assessment dated September 4, 2024, was not entered into the agency’s electronic system until October 21, 2024, by the Registered Nurse (RN). The OASIS ROC was transmitted on October 21, 2024. He stated the OASIS ROC was submitted over 30 days. 2. Patient 19 was admitted to the agency with the start of care (SOC) date of September 18, 2024, with diagnoses which included atrial fibrillation (an irregular heart beat that causes poor blood flow to the heart). The certification period from September 18, 2024 to November 16, 2024, indicated Patient 19 was discharged on October 12, 2024, due to hospitalization. The OASIS Discharge assessment was completed on October 12, 2024. The BC stated the OASIS Discharge assessment dated October 12, 2024, was submitted late on November 19, 2024. He stated he could not transmit the OASIS Discharge assessment timely when the RN was late in entering the OASIS Start of Care Assessment dated September 18, 2024. 3. Patient 20 was admitted to the agency with the start of care (SOC) date of September 10, 2024, with diagnoses which included immunodeficiency and Chronic Obstructive Respiratory Disease (COPD - lung disease). The certification period from September 10, 2024 to October 8, 2024, indicated Patient 20 was discharged on October 8, 2024. The OASIS Discharge assessment was completed on October 8, 2024. The BC stated the OASIS Discharge assessment dated October 8, 2024, was submitted late on November 19, 2024. He stated he could not transmit the OASIS Discharge assessment timely when the RN was late in entering the OASIS Start Of Care assessment dated September 10, 2024, into the agency’s electronic system. 4. Patient 21 was admitted to the agency with the start of care (SOC) date of November 11, 2022, with diagnoses which included Hepatic Encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood). The recertification period from November 15, 2024 to January 13, 2025, indicated the OASIS Recertification assessment was completed on November 15, 2024. The BC stated the OASIS Recertification assessment completed on November 15, 2024, was submitted late on December 17, 2024. He stated he could not submit the OASIS Recertification assessment timely to CMS when the RN was late in entering the OASIS Recertification assessment into the agency’s electronic system. 5. Patient 22 was admitted to the agency with the start of care (SOC) date of June 6, 2022, with diagnoses which included Chronic Kidney Disease. The recertification period from September 27, 2024 to November 13, 2024, indicated the OASIS Recertification assessment was completed on September 27, 2024. The BC stated the OASIS Recertification assessment completed on September 27, 2024, was submitted late on December 17, 2024. He stated he could not submit the OASIS Recertification assessment timely to CMS when the RN was late in entering the OASIS Recertification assessment into the agency’s electronic system. On January 9, 2025, at 4:45 p.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated she was not aware the OASIS transmission to CMS were late for Patients 18, 19, 20, 21, and 22). She stated she was not notified by the BC or by the Administrator. The agency was not able to provide a policy and procedure on OASIS transmission to CMS.”

“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 ensure an on going infection control program for the surveillance, identification, infection prevention control of infections and communicable diseases were maintained and implemented. This failure had the potential to affect the delivery of care and services specific to patients with infections and communicable diseases in home setting. In addition this failure had the potential to expose patients and caregivers to infections and development of other diseases. Findings: On January 13, 2025, at 3:20 p.m., a concurrent interview and review of the agency’s infection control log folder was conducted with the Director of Patient Care Services (DPCS). There was no documented evidence in the infection control binder indicating the agency’s surveillance program. The DPCS acknowledged the agency had no surveillance program in tracking the type of infections and other communicable diseases of the patients admitted to the agency for the past 12 months. The DPCS was not able to provide any policy and procedure related to infection control surveillance program.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to provide the 12 hours in-service training for three of three CHHA files reviewed. This failure had the potential to result in inadequate knowledge necessary for CHHA to deliver quality of care to in-home patients with skilled needs. Findings: On January 9, 2025, at 4:38 p.m., a concurrent interview and review of the agency’s in-service log was conducted with the Director of Nursing Services (DPCS). There was no documented evidence in the agency’s log the CHHAs 12 hours in-services were provided to the three CHHA’s employed by the agency. The DPCS acknowledged the 12 hours of in-service training for CHHA was not completed and met by the agency for the past 12 months. She stated she was responsible for providing the in service training to the CHHAs. On January 13, 2025, at 10:30 a.m., a telephone interview was conducted with CHHA 1. CHHA 1 stated she had not received the 12 hours in-services from the agency the past 12 months. The agency was not able to provide policy and procedure related to CHHA 12 hours in-service training.”

“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 patient’s current Plan of Care (POC) and current medication profile were updated, accurate, and complete for five patients reviewed (Patients 4, 5, 6, 7, and 1) when: 1. For Patient 4, Four medications that had been discontinued by the patient’s physician, or the patient had stopped taking the medication, were still listed on the current medication profile and POC. a. Potassium Chloride (a supplement for low potassium) 20 milligram (mg- a unit of measurement), one packet po (by mouth) daily. b. Topiramate (used to treat epilepsy) 50 mg one tablet po daily. c. Creon Oral 36000-114000 units (a supplement for pancreas) one capsule daily. d. Levothyroxine Sodium (a thyroid medication) 25 microgram (mcg - a unit of measurement) one tablet po daily. - One medication Icosapent Ethyl (used to treat high triglycerides, a fat-like substance) 1 gram (gm - a unit of measurement) po, had a change in dosage and frequency. - Seven medications Patient 4 was currently taking were not listed in the current POC and medication profile; a. “Methimazole (used to treat high thyroid level)10 mg one tablet po daily. Fill date : 9/9/24 b. Zonisamide (used for seizure) 100 mg. Take 2 caps po daily. Fill date: 7/23/24 c. Sertraline HCL (an antidepressant) 25 mg one tablet po daily. Fill date: 10/23/24 d. Tizanidine HCl ( a muscle relaxant) 4 mg 1 po BID e. Olanzapine (an antipsychotic) 15 mg one tablet po daily and f. Gemfibrozil (for high cholesterol) 600 mg one tablet po BID. g. Lactulose (used for constipation) 10 gm/15 milliliter (ml - a unit of measurement). Take 30 ml 3x (three times) a day as needed.” 2. For Patient 5, - One medication Paroxetine HCL (an antidepressant) had a change in the dosage from 20 mg to 30 mg po daily. - Four medications were not listed in the current POC and medication profile. a. Omeprazole 20 mg (used to treat indigestion and heart burn) one capsule daily. b. Hydroxyzine HCL (used to control anxiety) 25 mg one tablet po BID (twice a day). c. CoQ10 (an antioxidant) 100 mg one tablet po daily. d. ASA (Aspirin) 81 mg. one tablet daily; 3. For Patient 6, - Two medications the patient stopped taking were still listed in the current POC and medication profile. a. Tizanidine HCl (muscle relaxant) oral 4 mg one tablet prn (as needed) every 6 hours. b. Percocet (used for pain) oral 5-325 mg one tablet every 6 hours for pain 4-10. 4. For Patient 7, - Two medications listed in the POC and medication profile were not available in the patient’s home. a. Atorvastatin Calcium (used to lower cholesterol) 20 mg po daily. b. Fluticasone Propionate inhalation (used to treat asthma and allergies) 50 mcg one every 6 hours. -One medication Losartan Potassium (used to treat high blood pressure) 50 mg one tablet BID (twice a day) had a change in frequency. - Three medications were not listed in the current POC and medication profile. a. Fluticasone propionate nasal suspension nasal spray. b. Tylenol 500 mg one tablet po prn. c. Acetaminophen 325 mg - regular strength for pain reliever prn; and 5. For Patient 1, Nine medications were being taken by Patient 1 were not listed in the agency’s current POC. - a. Ranozaline ER (used for chest pain) 500 mg one tablet BID - b. Benzonatate (used for cough) 100 mg one capsule TID (three times a day) PRN (as needed). - c. Trelegy Ellipta (used for Chronic Obstructive Pulmonary Disease - lung disease). - d. Trifluridine ophthalmic (eye drop) solution 1gtt (drop) both eyes daily. - e. Latanoprost (used for glaucoma) 0-005% (percent) 1 gtt both eyes at night. - f. Prednisolone (used for catact surgery) 1% to both eyes daily. - g. Erythromycin (used to treat eye infection) ophthalmic ointment 0.5%, apply to both eyes daily. - h. Dorsalamide HCL (used for glaucoma) Timolol ophthalmic solution, 1 gtt to both eyes daily. - i. Brimonidine (used for glaucoma) 0.2% 1 gtt to both eyes TID. These failures had the potential for Patients 4, 5, 6, 7, 1, and their primary care givers (PCG) not to be able to identify the significant drug interactions, ineffective drug therapy and non-compliance with prescribed medications. 5. On January 6, 2025, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with the SOC date of October 25, 2024, with diagnoses which included hypertension (high blood pressure) and weakness on both feet. The following medications were listed for the certification period from December 24, 2024 to February 21, 2025: - Mupirocin Calcium Nasal (used to treat or prevent infections in the nose) 2% one apply with Q-tip into the nose twice daily for 14 days; - Nitroglycerin (used to treat and prevent chest pain) sublingual (placed under the tongue) 0.4 mg every five minutes times 3 as needed; - Coreg (used to treat high blood pressure) 3.125 mg 1 tablet BID; - Flomax (used to treat enlarged prostate) 0.4 mg 1 capsule daily; - Omeprazole (used to treat heartburn) 40 mg one capsule daily before meal; - Atorvastatin Calcium (used to treat high cholesterol) 40 mg one tablet at bedtime; and - Albuterol Sulfate (used to relieve chest congestion) inhalation one puff every four hours as needed. On January 7, 2025, at 2: 42 p.m., a home visit was conducted at Patient 1’s residence. A review of the medications currently taken by Patient 1 was conducted. The following medications were not listed in the agency’s current POC: - Ranozaline ER 500 mg one tablet BID; - Benzonatate 100 mg one capsule TID PRN; - Trelegy Ellipta one puff daily; - Trifluridine ophthalmic solution one gtt both eyes daily; - Latanoprost 0.005% 1 gtt both eyes at night; - Prednisolone 1% one gtt to both eyes daily; - Erythromycin ophthalmic ointment 0.5% apply to both eyes daily; - Dorsalamide Hydrocloride/Timolol Ophthalmic solution, one gttt to both eyes Daily; and - Brimonidine 0.2% one gtt to both eyes TID. On January 7, 2025, at 3:20 p.m., during an interview with LVN 5, she stated the Registered Nurse Supervisor conducts the initial medication reconciliation. She stated she would get a copy of POC. LVN 5 stated she would ask the primary care giver if there was a change in Patient 1’s medication and would write them out in her copy of the POC. She stated she did not enter the changes in Patient 1’s electronic medical record nor did she inform the agency of the changes. She stated she should have informed the agency of the changes or any new medication for Patient 1. LVN 5 also stated she did not compare Patient 1’s medication reconciliation against the medications Patient 1 was taking. LVN 5 stated she should have compared the medication profile at home, the POC and the actual medications Patient 1 was receiving at home. On January 9, 2025, at 9 a.m., the Director for Patient Care Services (DPCS) was interviewed. She stated it is the RN Supervisor (RNS) responsibility during the SOC and recertification visit to conduct a medication reconciliation and communicate with the office and the patient’s physician. She stated the RNS should give the patient/patient care giver a written information and instruction on medications. The DCPS also stated the skilled nurse should follow-up at least once a month for changes with the patient’s medication. The agency’s undated policy and procedure titled, “Medication Reconciliation Management,” indicated, “...Registered Nurse (RN) to pull out all patient’s current medications during Start of Care. Current medications are listed in the medication profile upon assessment. RN/LVN must reconcile any additional/removal medications by the M.D. into the medication profile. Medication list include anyn over the counter medications that are currently taken by the patient...” Findings: 1.On January 6, 2025, Patient 4’s record was reviewed. Patient 4 was admitted to the agency with the start of care (SOC) date of November 11. 2023, with diagnoses which included brain aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood) and partial paralysis of the left side of the body. The certification period from November 22, 2024 to January 20, 2025, indicated “SN (skilled nurse) to visit twice a week for 9 weeks...medication management due to hypertension...” On January 7, 2025, at 9 a.m., a home visit was conducted for Patient 4 with Licensed Vocational Nurse (LVN) 1. Patient 4 was observed sitting in the sofa alert, oriented, and able to verbalize her needs. Patient 4 was observed with AFO (ankle-foot orthoses, a supportive devises for foot and ankle) on her left leg and brace (a device used to support a weak or injured part of the body) on her left arm. Patient 4 was observed walking independently. On January 7, 2025, at 9:36 a.m., a concurrent interview and medication reconciliation was conducted with LVN 1 and Patient 4. During the medication reconciliation the following were observed: - The four medications Potassium Chloride, Topiramate, Creon Oral, and Levothyroxine Sodium were not available for use. Patient 4 stated she had not taken the medication Potassium Chloride for six months, the Topiramate had been discontinued by her physician for three months, the Creon Oral had been discontinued by her stomach doctor for a while, and the Levothyroxine was discontinued and replaced by another medication; - One medication Icosapent Ethyl oral 1 gm, 1 capsule TID was changed to 1 gm 2 capsules BID with meals. Patient 4 stated she had been taking the medication for a while and could not remember when the physician had changed the dose and frequency; - Seven medications Methimazole, Zonisamide, Sertraline, Tizanidine HCl, Olanzapine, Gemfibrozil and Lactulose were currently being used by Patient 4, were not listed in the agency’s current POC and medication profile. Patient 4 stated she had taken the seven medications for a while. LVN 1 stated she was not able to update Patient 4’s medication profile in the agency’s electronic system. She stated she was not aware of the other medications Patient 4 had been taking for a while. She stated she did not check all the prescriptions bottles Patient 4 were using. 2. On January 6, 2025, Patient 5’s record was reviewed. Patient 5 was admitted to the agency with the start of care (SOC) date of April 18, 2022, with diagnoses which included hypertension (high blood pressure). The certification period from December 3, 2024 to January 31, 2025, indicated “SN (skilled nurse) visit twice a week for nine weeks...SN to determine if the Patient/Caregiver is able to identify the correct dose, route, and frequency of each medication...SN to instruct the Patient/Caregiver on medication regimen dose, indications, side effects, and interactions...” On January 7, at 11:05 a.m., a home visit was conducted for Patient 5 with LVN (Licensed Vocational Nurse) 2. Patient 5 was observed sitting in her recliner chair, alert, oriented and able to verbalize her needs. On January 7, 2025, at 11:18 a.m., a concurrent interview and medication reconciliation was conducted with Patient 4 and LVN 2. During the medication reconciliation the following were observed: - One medication Paroxetine HCL oral 20 mg one po at HS (at night) was not available for use. Patient 4 was currently taking Paroxetine HCL 30 mg one tablet po daily. Patient 4 stated the medication was changed by her physician on July 2024, when she lost her husband on March 2024, and sister-in-law on April 2024. She stated it helped her a lot. - Four medications Omeprazole, Hydroxyzine HCL, CoQ10, and Aspirin were not listed in the agency’s current POC and medication profile. Patient 4 stated she had taken the Omeprazole since 2012, the Hydroxyzine HCL for 5 years, the CoQ10 for one year, and the Aspirin for 11 years. On January 7, 2025, at 12:05 p.m., LVN 1 stated she was not aware of Patient 5’s medication changes. She stated she will do a better job on medication reconciliation. 3. On January 6, 2025, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with the start of care (SOC) date of November 11, 2021, with diagnoses which included spondylosis (a wear and tear of the spinal disks). The certification period from December 25 to February 22, 2025, indicated “SN (skilled nurse) 2x W9 (Two times a week for nine weeks)...SN to instruct the Patient/Caregiver on medication regimen dose, indications...” On January 7, 2025, at 12:50 p.m., a home visit was conducted for Patient 6 with Licensed Vocational Nurse (LVN) 3. LVN 3 stated she had been taking care of Patient 6 for three years. She stated Patient 6 had caregivers and managed his own medications. Patient 6 was observed sitting in his motorized wheelchair, alert, oriented and able to verbalize his needs. On January 7, 2025, at 1:23 p.m., a concurrent interview and medication reconciliation was conducted with Patient 6 and LVN 3.\ During the medication reconciliation two medications Tizanidine HCL 4 mg and Percocet oral 5-325 mg were not available for use. Patient 6 stated he stopped using the medications about two months ago. LVN 3 stated she was not aware Patient 6 had stopped using the medications. 4. On January 6, 2025, Patient 7’s record was reviewed. Patient 7 was admitted to the agency with the start of care (SOC) date of December 18, 2024, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a lung disease). The certification period from December 12, 2024 to February 15, 2025, indicated a physician order of “...SN (skilled nurse) 2xWx9 (two times a week for 9 weeks)...SN to instruct the Patient/Caregiver on medication regimen, indications, side effects, and interactions...” On January 7, 2025, at 3 p.m., a home visit was conducted for Patient 7 with Licensed Vocational Nurse (LVN) 4. Patient 4 lives in the assisted living facility. Patient 7 was alert, oriented, and able to verbalize her needs. She was using continuous oxygen at two liters per nasal (through the nose) cannula (a plastic tubing that delivers oxygen through the nostrils). On January 7, 2025, at 4:05 p.m., a concurrent interview and medication reconciliation was conducted with Patient 7 and LVN 4. During the medication reconciliation the following were observed: - Two medications Atorvastatin Calcium oral was available and ready for use. Patient 7 stated she had not taken the medication for two to three months. She stated she scheduled an appointment with her cardiologist and will let him know. The medication Fluticasone Propionate inhalation was not available. Patient 4 stated she had not used the inhalation for a while. - One medication Losartan Potassium 50 mg one tablet BID, Patient 7 stated she only takes the medication one tablet daily. - Three medications Fluticasone propionate nasal suspension spray, Tylenol 500mg po, Acetaminophen 325 mg, were not listed in Patient 7’s POC. Patient 7 stated she had been using the medications for a while. LVN 4 stated she did not know all these changes in Patient 7’s medication. On January 8, 2025, at 4:01 p.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated the Registered Nurses were responsible in conducting the initial comprehensive assessments which included the patients medication reconciliations and the Licensed Vocational Nurses (LVN) were responsible in asking the patients for any changes in their medications. She stated the LVN should constantly follow up any changes in their patients medications and should include ant over the counter medications.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician’s verbal orders were signed and dated timely, within 30 days of order date for ten of 17 patients reviewed (Patients 1, 4, 5, 6, 8, 9, 12,14, 15, and 16). This failure resulted in verbal orders not authenticated and dated by the physician in accordance with the agency’s policy and procedure. In addition this failure had the potential to result in incorrect verbally ordered medications and treatment for patients which could cause unnecessary care and services. Findings: 1. On January 6, 2025, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with the start of care (SOC) date of October 25, 2024, with diagnoses which included hypertension (high blood pressure). Patient 1’s Plan of Care (POC) for the certification period from October 25, 2024 to December 23, 2024, was signed and dated on January 9, 2025. The verbal orders in the POC were signed and dated over 30 days. 2. On January 6, 2025, Patient 4’s record was reviewed. Patient 4 was admitted to the agency with the SOC date of November 28, 2023, with diagnoses which included brain aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood). Patient 4’s POC for the certification period from July 25, 2024 to September 22, 2024, was signed and dated on January 9, 2025. The verbal orders in the POC were signed and dated over 30 days. Patient 4’s POC for the certification period from November 22, 2024 to January 20, 2025, was not signed and dated. The verbal orders in the POC were not signed and dated within 30 days. 3. On January 6, 2025, Patient 5’s record was reviewed. Patient 5 was admitted to the agency with the SOC date of April 18, 2022, with the diagnoses which included hypertension (high blood pressure). Patient 5’ POC for the certification period from August 5, 2024 to October 3, 2024, was signed and dated October 24, 2024. The verbal orders in the POC were signed over 30 days. Patient 5’s POC for the certification period from October 4, 2024 to December 2, 2024, was signed and dated January 9, 2025. The verbal orders in the POC were signed over 30 days. Patient 5’s current POC for the certification period from December 3, 2024 to January 31, 2025, was not signed. The POC was not signed and dated within 30 days of the order date. 4. On January 6, 2025, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with the SOC date of November 11, 2021, with diagnoses which included spondylosis ((arthritis of the spine). Patient 6’s POC for the certification period from October 26, 2024 to December 24, 2024, was signed and dated December 16, 2024. The verbal orders in the POC were signed and dated over 30 days. 5. On January 6, 2025, Patient 8’s record was reviewed. Patient 8 was admitted to the agency with the SOC date of December 6, 2024, with diagnoses which included acute kidney failure. Patient 8’s POC for the certification period from December 6, 2024 to February 3, 2025, was not signed and dated. The verbal orders in the POC were not signed and dated within 30 days. 6. On January 6, 2025, Patient 9’s record was reviewed. Patient 9 was admitted to the agency with the SOC date of November 22, 2024, with diagnoses which included cellulitis (bacterial skin infection) of the left lower leg. Patient 9’s POC for the certification period from November 22, 2024 to January 20, 2025, was signed and dated on January 13, 2025. The verbal orders in the POC were signed and dated over 30 days. 7. On January 6, 2025, Patient 12’s record was reviewed. Patient 12 was admitted to the agency with the SOC date of December 2, 2024, with diagnoses which included hypertension and repeated falls. Patient 12’s POC for the certification period from December 2, 2024 to January 30, 2025, was not signed. The verbal orders in the POC were not signed within 30 days of the order date. 8. On January 6, 2025, Patient 14’s record was reviewed. Patient 14, was admitted to the agency with the SOC date of January 30, 2024, with diagnoses which included pressure ulcer in the sacrum (lower back of the spine). The POC for the certification period from September 26, 2024 to November 24, 2024, was signed on January 9, 2025. The verbal orders in the POC were signed and dated over 30 days. Patient 14 was discharged on November 24, 2024. 9. On January 6, 2025, Patient 15’s record was reviewed. Patient 15 was admitted to the agency with the SOC date of September 24, 2024, with diagnoses which included hypertension (high blood pressure). The POC for the certification period from September 24, 2024 to November 22, 2024, was not signed and dated. The orders in the POC were not signed and dated within 30 days. Patient 15 was discharged on September 28, 2024. 10. On January 6, 2025, Patient 16’s record was reviewed. Patient 16 was admitted to the agency with the SOC date of May 30, 2024, with diagnoses which included weakness and hypertension. The POC for the certification period from May 30, 2024 to July 28, 2024, was signed on January 10, 2025. The orders in the POC were signed over 30 days. Patient 16 was discharged on July 28, 2024. On January 9, 2024, at 12:56 p.m., the agency’s staff (AS) in charge of sending the 485 form (POC) for signature was interviewed. The AS stated the Registered Nurse will generate the POC at the start of care, and she (the AS) will fax and mail the POC to the physician’s office. She stated the POC forms were supposed to be signed within 30 days. She stated she did not track the POCs that were sent out to the physicians. She stated the physicians’ verbal orders for Patients 1, 4, 5, 6, 8, 9, 12,14, 15 and 16 were not signed timely within 30 days of the order dates. On January 9, 2024, at 4:45 p.m., the Director of Patient Care Services (DPCS ) was interviewed. The DPCS stated she was not aware the agency was not receiving the 485 form (POC) timely. She stated the physician’s verbal orders should be signed within 30 days of the order dates. The agency’s policy and procedure dated October 2004, titled, “Orders for medication and treatment,” indicated, “...No medication or treatment shall be given except on signed orders of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient’s physician...within 30 working days...””

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge OASIS (Outcome and Assessment Information Set – an assessment tool), was signed by the Registered Nurse Supervisor (RNS), for five of five discharged patients reviewed (Patients 13, 14, 15, 16, and 17). This failure had the potential for the discharged patients not to receive the appropriate discharge instructions signed by the RNS. Findings: On January 9, 2025, Patient 13’s record was reviewed. Patient 13 was admitted to the agency on June 11, 2024, with diagnoses which included unstageable pressure ulcer (a type of bed sore) of sacral region (base of the lower spine) and hypertension (high blood pressure). The discharge OASIS dated October 23, 2024, indicated the document was signed by the billing coordinator (BC) and not by the RNS. On January 9, 2025, Patient 14’s record was reviewed. Patient 14 was admitted to the agency on January 30, 2024, with diagnoses which included pressure ulcer to sacral area. The discharge OASIS dated November 24, 2024, indicated the document was signed by the BC and not by the RNS. On January 9, 2025, Patient 15’s medical record was reviewed. Patient 15 was admitted to the agency on September 24, 2024, with diagnoses which included hypertension. The discharge OASIS dated September 28, 2024, indicated the document was signed by the BC and not by the RNS. On January 9, 2025, Patient 16’s medical record was reviewed. Patient 16 was admitted to the agency on May 30, 2024, with diagnoses which included hypertension. The discharge OASIS dated July 11, 2024, was signed by the BC and not by the RNS. On January 9, 2025, Patient 17’s record was reviewed. Patient 17 was admitted to the agency on August 11, 2023, with diagnoses which included schizophrenia (a mental illness). The discharged OASIS dated August 15, 2024, was signed by the BC and not by the RNS. On January 13, 2025, at 11:30 a.m., the Director for Patient Care Services (DPCS) was interviewed. She stated all patient discharges should be conducted and signed by the RNS who initiated the start of care for the patient. She stated the patient should be assessed and given discharge instructions unless the patient refused, did not want to be seen, or was hospitalized prior to the discharge date. She also sated she was not aware the BC was signing the discharge OASIS. On January 9, 2025, at 2:09 p.m., during a telephone interview with the BC, he stated he oversaw the discharge OASIS since 2002. He stated he was signing the discharge OASIS to have the claims done. He stated he was not aware he should have not signed the discharge OASIS. The agency was not able to provide a written policy and procedure for documenting and signing for OASIS discharge.”

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on interview and record review, the agency failed to perform and complete the Certified Home Health Aide (CHHA) annual competency evaluation for three of three CHHA files reviewed (CHHA 1, 2, and 3). This failure had the potential to affect CHHA’s skills and performance in providing in-home care to patients with various needs, which could impact the delivery of care and services to complex patients receiving skilled services. Findings: On January 13, 2025, three CHHA files were reviewed. The following documents were reviewed: - CHHA 1 was hired on May 9, 2019. There was no documented evidence in CHHA 1’s personnel file indicating the annual skills and competency evaluation was completed by the agency; - CHHA 2 was hired on June 12, 2024. There was no documented evidence in CHHA 2’s personnel file indicating the annual skills and competency evaluation was completed by the agency; and - CHHA 3 was hired on March 9, 2020. There was no documented evidence in CHHA 3’s personnel file indicating the annual skills and competency evaluation was completed by the agency. On January 13, 2025, at 10:30 a.m., a telephone interview was conducted with CHHA 1. CHHA 1 stated she only received one performance evaluation since she started with the agency. On January 13, 2025, at 5:37 p.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated the CHHA annual skills and competency evaluations were not completed. She stated she was responsible for performing the CHHA’s annual performance evaluation of their skills and competency. The DPCS was not able to provide the agency’s policy and procedure related to CHHA skills and competency evaluation.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to conduct supervisory visits every 14 days for three of three Certified Home Health Aides (CHHAs) reviewed. This failure had the potential for the patient not to have the plan for personal care followed by the CHHA. Findings: On January 6, 2025, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with a Start of Care (SOC) date of October 25, 2024, with diagnoses which included hypertension (high blood pressure) and weakness on both feet. Patient 1’s certification period from October 25, 2024 to December 23, 2024, indicated a physician’s order, “…HHA (Home Health Aide) 2x/week x 9/weeks (two times per week for 9 weeks) …” and for certification period from December 24, 2024 to February 21, 2025, “…HHA 2x/week x 9 /weeks…” Supervisory visits were conducted on October 29, 2024, and December 24, 2024, for CHHA 2. On January 13, 2025, Patient 23’s record was reviewed. Patient 23 was admitted to the agency with SOC date of July 30, 2024, with diagnoses which included osteoarthritis (a joint disease). Patient 23’s certification period from September 28, 2024 to November 26, 2024, indicated “…PATIENT IS CURRENTLY SCHEDULED FOR 2 DAYS A WEEK AT 18 UNITS (18 times) and for the certification period from November 27, 20224 to January 25, 2025, indicated physician’s order, “…HHA 2x/week x 9/weeks…” Supervisory visits were conducted on September 28, 2024, and November 27, 2024, for CHHA 1. On January 13, 2025, Patient 24’s record was reviewed. Patient 24 was admitted to the agency with SOC date of November 27, 2024, with diagnoses which included hypertension. Patient 24’s certification period from November 27, 2024 to January 25, 2025, indicated, “…HHA 2x/week…” A supervisory visit was conducted on December 20, 2024, for CHHA 3. On January 13, 2024, at 10:30 a.m., during a telephone interview with CHHA 1, she stated the licensed nurse made her supervisory visit monthly. On January 13, 2024, at 4:35 p.m., during an interview with the Director of Patient Care Services, she stated the agency conducted supervisory visits for CHHA at least once a month. The agency was not able to provide a policy and procedure for supervisory visit.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Director of Patient Care Services (DPCS) was involved in the overall coordination of patient care. This failure resulted with the DPCS lacking supervision in coordinating patient care. In addition, this failure had the potential to affect delivery of care and services. Findings: On January 6, 2025, at 9:30 a.m., during an interview with the Intake Coordinator (IC), she stated the Administrator (ADM) was out of the country. The IC stated the Director for Patient Care Services (DCPS) had another job and was available through telephone calls. She also stated the Registered Nurse Supervisor (RNS) was in-charge while the DPCS was not available in-person. On January 6, 2025, at 10:30 a.m., during an interview with the RNS, she stated she was always available for staff assistance and questions. She stated if the DPCS was not in the office, staff and clinicians would go to her or call her for assistance. The RNS stated she would not know where to find the agency’s policies and procedures. She stated she was not involved with some of the administrative tasks. On January 9, 2025, at 11:30 a.m., during an interview with the DPCS, she stated she was not aware the billing coordinator was signing the discharge OASIS document (a standardized tool used by home health agencies to collect and report information and development of plans of care). She stated the BC should not be signing the discharge OASIS. On January 9, 2025, at 4:45 p.m., the DPCS was interviewed and stated she was not aware OASIS transmission to CMS was late for five patients, and that she was not aware the agency was not receiving the signed plans of care (POC’s) timely. On January 9, 2025, at 5 p.m., during an interview with the DPCS, the DPCS was not aware of the current regulations for home health agency (HHA). She asked how and where to find the regulations and guidelines for HHAs. On January 13, 2025, at 5:37 p.m., the DPCS was interviewed and stated Certified Home Health Aide (CHHA) annual skills and competency evaluations were not completed and that she was responsible for performing the skills and competency evaluations. During a review of the undated document titled, “JOB DESCRIPTION FOR (NAME OF THE DPCS), the document indicated, “…She is the head of all clinics…Responsibility…overall supervisor for all nursing staff…reviews all their clinical notes and approves or disapprove…conducts start of care (SOC) and recertification of patients when necessary…receives the clinical notes of the therapist…conduct in service training to nursing clinicians…””