Homeliving Health Providers, Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing care to home bound patients [patients with difficulty leaving the house]) failed to ensure the Conditions of Participations regarding Patient Rights was met as follows: ---Failed to investigate patient’s complaint and report an assessment of patient’s condition which might indicate an alleged abuse or neglect to the director of patient care services (DPCS) who will assign a supervisor to assess the patient for abuse or neglect in accordance with their policy and procedure for one of ten sample patients (Patient 1). This deficient practice had resulted in the violation of the patient’s right of the complaint presented to be investigated promptly for injuries and or mistreatment affecting the patient’s overall health status. Refer to G478. ---Failed to report immediately allegation of staff’s physical abuse and/or neglect for one of ten sampled patients (Patient 1) to the appropriate authority in accordance with the State law. The deficient practice resulted in the delay of the HHA staff, and individuals legally responsible to report suspicion of physical abuse and/or neglect to appropriate State authorities jeopardizing the health and safety of the patient. Refer to G488. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Patient Rights to ensure patients’ rights are not violated for certified patients receiving the home health benefits.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to follow all physician’s orders in the individualized Plan of Care (POC [documents the process of identifying a patient’s needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) for one of ten samples patients (Patient 1). This deficient practice had the potential to result in Patient 1 not receiving the needed care, services, and treatments as prescribed by the physician in the POC that could affect the patient’s health status and well-being. During a review of Patient 1’s patient record titled, Patient Demographics, undated, indicated a Start Of Care (SOC) date of 10/5/2022, with a primary diagnosis of Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a long-term condition that results in the inability to effectively exchange carbon dioxide and oxygen, and causes low oxygen levels or high carbon dioxide levels in the body). During a review of Patient 1’s record titled, Home Health Certification and Plan Of Care (a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for the certification period of 9/24/2024 to 11/22/2024, indicated Patient 1 to have in home skilled nursing care at 240-378.67 hours per month. During an interview on 10/29/2024 at 12:20pm with the Director of Patient Care Services (DPCS), the DPCS stated the HHA is under a waiver program that dictates what type of care and how much/often the skilled nurses will provide to patients. The DPCS stated the HHA is like respite care, and the patient’s primary caregiver is responsible to take over care of the patient if a nurse is not available. The DPCS stated some patients can go weeks without being staffed a skilled nurse due to unavailability or not being able to find the right nurse, and the HHA is the supplemental help. During a concurrent interview and record review on 10/29/2024 at 2:35pm with the DPCS, Patient 1’s record titled Home Health Certification and Plan of Care, for the certification period of 9/24/2024 to 11/22/2024 was reviewed. Patient 1’s Home Health Certification and Plan of Care indicated an order for Patient 1 to have in home skilled nursing care at 240 – 378.67 hours/month. The DPCS stated the Home Health certification and Plan of Care is a physician order and are to be followed by the skilled nurse and HHA. The DPCS further stated Patient 1 has not had a skilled nurse assigned from 10/13/2024 to now. During a concurrent interview and record review on 10/29/2024 at 12:50m with the Director of Patient Care Services (DPCS), the HHA admission consents and packet were reviewed. The HHA admission consents indicated there was no documented evidence that patient’s caregiver is responsible to take over care of the patient when a skilled nurse is not available or staffed. The DPCS stated that information is mentioned in the waiver program consents that the patients and families’ sign. During a home visit on 10/30/2024 at 11:05 am at Patient 1’s home, Patient 1 was observed in bed with head of the bed elevated, nonverbal, patient eyes were open and following movement, and with a tracheostomy tube (a tube inserted into a surgically created opening in the windpipe to help a person breather and clear secretions from their lungs) to oxygen concentrator (a machine that separates oxygen from the air in a room to provide oxygen therapy). Patient 1 Family Member lifted bed sheet form Patient 1’s lower legs and it was observed Patient 1 had yellow/green discoloration to the top of the right and left foot. There was no skilled nurse assigned to Patient 1. During an interview on 10/30/2024 at 11:05am at Patient 1’s home with Patient 1 Family Member, Patient 1 Family Member stated Patient 1 has been without a skilled nurse since LVN 1 was last there on 10/12/2024 and prior to that Patient 1 was without a skilled nurse for one month. During a concurrent interview and record review on 11/1/2024 at 3pm with the DPCS, Patient 1’s record titled Discipline visit detail, with dates from 10/5/2022 to 10/30/2024 was reviewed. Patient 1’s Discipline visit detail record indicated Patient 1 was not assigned a skilled nurse during the dates of 9/10/2024 to 10/12/2024 and from 10/13/2024 to now. The DPCS stated Patient 1 did not have a skilled nurse assigned due to unavailability and not being able to find a skilled nurse fit for Patient 1 and Patient 1 Family Member needs. During a review of the HHA’s Policy and Procedure (P&P) titled, Plan of Care- CMA #485 and Physician/Practitioner Orders, with a revised date of February 2024, indicated, “3. Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician”.”

“Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure Licensed Vocational Nurses (LVN) furnishing home health services for three of ten sampled patients (Patient 8, Patient 9, Patient 10) shall have one year prior professional nursing experience in accordance with Title 22 regulation section 74707 (d). The deficient practice had the potential to result in patients certified for HHA services receiving substandard care jeopardizing their health, safety, and wellbeing. A. LVN 3’s personnel file was reviewed. The job application indicated LVN 3 started working at the HHA on 8/16/2024. A review of LVN 3’s Resume (summary of experiences, skills, and work history), indicated LVN 3 had no prior nursing experience. A review of LVN 3’S Board of Vocational Nursing and Psychiatric Technicians license details, indicated LVN 3 was issued an LVN license on 7/18/2024. During a record review of Patient 8’s Patient Demographics, the Patients Demographics indicated a start of care on 1/18/2023 with a primary diagnosis of Quadriplegia, unspecified (a condition that causes paralysis in all four limbs and the body from the neck down). During a record review of LVN 3‘s Care Staff Actual Visits, indicated LVN 3 was assigned and visited Patient 8 from 8/21/2024 to 10/23/2024. During an interview on 11/1/2024 at 11:30 am., with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, “we counted the CNA experience (Certified Nurse Assistant) as experience for LVN 3, because we were under the impression that every two years of CNA experience can be counted as one year of nursing experience.” B. LVN 4’s employee file was reviewed. The job application indicated LVN 4 started working at the HHA on 3/18/2024. A review of LVN 4’s Resume, indicated LVN 4 had no prior nursing experience. During a record review of LVN 4’S Board of Vocational Nursing and Psychiatric Technicians license details, indicated LVN 4 was issued an LVN license on 3/25/2024. During a record review of Patient 9’s Patient Demographics, the Patients Demographics indicated a start of care on 11/19/2022 with a primary diagnosis of spastic quadriplegic cerebral palsy (developmental disorder caused by damage to the brain before birth, during delivery, or within the first few years of life. This condition prevents the normal development of motor function characterized by jerky movements, muscle tightness, and joint stiffness). During a record review of LVN 4‘s Care Staff Actual Visits, indicated LVN 4 was assigned and visited Patient 9 from 3/27/2024 to 9/29/2024. During an interview on 11/1/2024 at 11:35 am with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, “we counted the CNA experience (Certified Nurse Assistant) as experience for LVN 4, because we were under the impression that every two years of CNA experience can be counted as one year of nursing experience.” C. LVN 5’s employee file was reviewed. The job application indicated LVN 5 started working at the HHA on 8/16/2024. A review of LVN 5’s Resume, indicated LVN 5 had no prior nursing experience. During a review of LVN 5’s Board of Vocational Nursing and Psychiatric Technicians license details, indicated LVN 5 was issued an LVN license on 7/5/2024. During a record review of Patient 10’s Patient Demographics, the Patients Demographics indicated a start of care on 1/14/2023 with a primary diagnosis of chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a long term condition that occurs when the lungs can’t exchange oxygen and carbon dioxide properly). During a record review of LVN 5‘s Care Staff Actual Visits, indicated LVN 5 was assigned and visited Patient 10 from 8/18/2024 to 9/15/2024. During an interview on 11/1/2024 at 11:40 am., with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, “We counted the CNA experience (Certified Nurse Assistant) as experience for LVN 5, because we were under the impression that every two years of CNA experience can be counted as one year of nursing experience.””

“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 Home Health Agency (HHA, agency providing care to home bound patients [patients with difficulty leaving the house]) staff failed to investigate patient’s complaint and report an assessment of patient’s condition which might indicate an alleged abuse or neglect to the director of patient care services (DPCS) who will assign a supervisor to assess the patient for abuse or neglect in accordance to their policy and procedure for one of ten sample patients (Patient 1). This deficient practice had resulted in the violation of the patient’s right of the complaint presented to be investigated promptly for injuries and or mistreatment affecting the patient’s overall health status. During a review of Patient 1’s record titled, “Patient Demographics” undated, indicated a Start of Care (SOC) date of 10/5/2022, with a primary diagnosis of chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a long-term condition that results in the inability to effectively exchange carbon dioxide and oxygen, and causes low oxygen levels or high carbon dioxide levels in the body). During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care” (a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for the certification period of 9/24/2024 to 11/22/2024, indicated Patient 1 was provided an in-home skilled nursing care from 240 hours to 378.67 hours per month. During an interview on 10/29/2024 at 12:20 pm., with the DCPS stated, the agency had received a grievance from Patient 1’s Family Member of alleged abuse, stating that Patient 1 obtained bruises from the Range of Motion (ROM) exercises performed by the Licensed Vocation Nurse 1 (LVN 1) on 10/12/2024 home visit. The DPCS stated the complaint was received on 10/18/2024. The DPCS stated the HHA did the incident report at the time the incident was reported, statements were gathered from both parties and LVN 1 was removed from Patient 1’s case, and reported the incident to Patient 1’s physician. The DPCS stated she interviewed LVN 1 over the phone and LVN 1 stated she did range of motion exercises on Patient 1 and was never asked to stop by Patient 1’s Family Member, did not have any arguments with Patient 1’s Family Member and was not aware of Patient 1 having bruises. The DPCS stated the incident was not reported to the Department of Health or other appropriate authorities because after reviewing the email statements from LVN 1 and Patient 1’s Family Member and pictures of Patient 1’s bruises, DPCS did not find the incident to be abuse, as Patient 1 Family Member did not say it was abuse. The DPCS stated she did not send a nurse to Patient 1’s home to assess Patient 1 after completing the incident report, stated the investigation was based on review of email statements and pictures of Patient 1’s bruises. The DPCS further stated LVN 1 left the HHA shortly after due to not having enough working hours. The DPCS stated allegations of abuse should be reported to appropriate authorities. During a concurrent interview and record review on 10/29/2024 at 12:36 pm., with the Director of Patient Care Services Designee (DPCSD), the Incident report for Patient 1, dated 10/12/2024 was reviewed. The incident report for Patient I indicated that per the patient caregiver, the skilled nurse completed passive range of motion on Patient 1, used excessive force causing mild bruising on bilateral lower extremities, and the documented corrective actions was skilled nurse removed off the case. The incident report also indicated in the illustration diagram an “I” for injury to right and left top of foot. The incident report for Patient 1 further indicated a signature of person completing the report from Registered Nurse 1 (RN 1). The DPCSD stated RN 1 completed the incident report and the DPCS interviewed LVN 1, and both parties were asked to submit an email statement of the incident. The DPCSD stated the investigation of the incident with Patient 1 consisted of review of interview and email statements from Patient 1 Family Member and LVN 1 and, photos of Patient 1’s bruises. During an interview on 10/29/2024 at 1:32 pm., with RN 1, RN 1 stated she was contacted by Patient 1 Family Member on 10/18/2024 via text message about the incident that occurred on 10/12/2024, and she reached out to him via phone call that same day. RN 1 stated Patient 1’s Family Member stated the exercises that LVN 1 performed on Patient 1 made Patient 1 uncomfortable and told LVN 1 not to use too much force during the exercises. RN 1 stated she asked Patient 1’s Family Member to send an email statement to the Home Health Agency (HHA), as to what happened that day, along with any pictures of the bruises on Patient 1. RN 1 stated she completed the incident report for Patient 1 on 10/18/2024 the day it was reported to her, and next went through the chain of command, communicating this with the DPCS. RN 1 stated the DPCS interviewed LVN 1 and requested from LVN to send an email statement to the HHA of what occurred on 10/12/2024 with Patient 1. RN 1 stated she also reported it to Patient 1’s physician. RN 1 stated she received the email statement with pictures, from Patient 1’s Family Member on 10/21/2024, and received the email statement from LVN 1 on 10/22/2024. RN 1 stated she did not go to Patient 1’s home to assess the patient after receiving the report of the incident, and no other nurse was sent to assess Patient 1. RN 1 further stated once the incident reported was completed, LVN 1 was removed off Patient 1’s case. RN 1 stated the incident was not reported to other appropriate authorities, like department of public health. RN 1 stated, she did inform Patient 1’s Family Member that the HHA was investigating the incident and LVN 1 was removed off the case. During a home visit on 10/30/2024 at 11:05 am., at Patient 1’s home, Patient 1 was observed in bed with head of the bed elevated, nonverbal, patient eyes were open and following movement, and with a tracheostomy tube (a tube inserted into a surgically created opening in the windpipe to help a person breather and clear secretions from their lungs) to oxygen concentrator (a machine that separates oxygen from the air in a room to provide oxygen therapy). Patient 1’s Family Member lifted bed sheet form Patient 1’s lower legs and it was observed Patient 1 had yellow/green discoloration to the top of the right and left foot. During an interview on 10/30/2024 at 11:20 am., at Patient 1’s home with Family Member, Patient 1’s Family Member stated he received a phone call from LVN 1 on 10/11/2024 stating she would be going to his home the next day and was aware of Patient 1’s case and knew where to go and what to do. Patient 1’s Family Member stated LVN 1 arrived at his home on 10/12/2024 around 7:30 am., to 7:40 am., and was “disturbed”, discussing to him about her personal matters, stated he talked to her to help her calm down. Patient 1 Family Member stated he interviewed LVN 1 first before taking her to the room to introduce LVN 1 to Patient 1. Patient 1 Family Member stated that LVN 1 mentioned to him she would do some range of motion exercises on Patient 1, and Patient 1 Family member stated he gave LVN 1 space to do so and went along with her plan as LVN 1 had mentioned she knew about Patient 1’s case. Patient 1 Family Member then stated Caregiver 1 brought it to his attention that LVN 1 was doing exercises on Patient 1 that they were not used to doing. Patient 1 Family Member stated that was when he walked into the room and saw LVN 1 applying pressure on Patient 1’s feet pushing them in a flex position, applying pressure on Patient 1’s right and left leg and putting her arm underneath the knee and bending the lower leg in a flex position. Patient 1’s Family Member stated LVN 1 was performing these exercises on Patient 1 in a fast and rough movement, stated Patient 1 was not used to it as she was delicate. Patient 1’s Family Member stated he noticed Patient 1 trembling and tears coming down her eyes. Patient 1 Family Member stated he asked LVN 1 to stop doing the exercises on Patient 1 and asked her to leave the room. Patient 1’s Family Member stated he spoke with LVN 1 in the living room area, told LVN 1 that he did not want LVN 1 to stay the 12 hours that day to care for Patient 1, and instead be there for 10 hours. Patient 1’s Family Member stated two to three days after LVN 1 had performed the exercises on Patient 1, he noticed the bruises on Patient 1. Patient 1 Family Member stated Patient 1 had green/yellow bruises to the left top of the foot, right top of the foot, and one of her shins (front part of the lower leg) and took pictures of the bruises. Patient 1’s Family Member stated he first reached out to the waiver program Social Worker (SW) to report the incident and bruises. Patient 1’s Family Member stated on 10/18/2024 he then reached out to the HHA via phone call, no answer and then sent a text message to RN 1, that included one picture of one of the bruises claiming LVN 1 had caused. Patient 1 Family Member further stated, RN 1 called him back and asked him to send an email statement describing how the incident occurred along with any pictures of the bruises he had. Patient 1’s Family Member stated he did send his email statement and pictures to the HHA on 10/21/2024. Patient 1’s Family Member stated since then he had not received a follow up response about the incident from the HHA. During an interview on 10/30/2024 at 12:45pm at Patient 1’s home with Caregiver 1, Caregiver 1 stated she was present in Patient 1’s home on 10/12/2024 with LVN 1. Caregiver 1 stated she observed LVN 1 doing massages and exercises on Patient 1 to her legs and arms that were too hard and fast. Caregiver 1 stated she observed LVN 1 massaging Patient 1’s right and left leg in a squeezing motion applying hard pressure and moving the right and left leg up and down in a fast pace. Caregiver 1 then stated she told LVN 1 to stop, that was not the way they did exercises on Patient 1. LVN 1 responded back to Caregiver 1 by saying she was the nurse, not her. Caregiver 1 further stated she told Patient 1’s Family Member how she saw LVN 1 provided massage and exercises to Patient 1 and noticed Patient 1 was trembling from her body. Caregiver 1 stated Patient 1 Family Member asked LVN 1 to stop and leave the room and spoke with LVN 1 in the living room telling her she would not stay with them the 12 hours. Caregiver 1 stated LVN 1 did not go back in Patient 1’s room and left around 5 pm. During a phone interview on 10/31/2024 at 11:30 am., with LVN 1 stated, she did a home visit for Patient 1 on 10/12/2024. LVN 1 stated she performed range of motion exercises to all four extremities on Patient 1 two times. LVN 1 stated she performed range of motion on Patient 1 gently, moving both arms and legs up and down, stated she did 25 repetitions to each extremity. LVN 1 further stated she did everything according to Patient 1’s Plan of Care. LVN 1 stated she was never told to stop by Caregiver 1 or Patient 1’s Family Member and did not have any arguments with Patient 1 Family Member. LVN 1 stated Patient 1’s Family Member then told her she would not be staying the 12-hour shift, only 10 hours and did not give her an explanation. LVN 1 stated at 5 pm., she left Patient 1’s home and did not return. LVN 1 stated the HHA agency contacted her a few days later and told her Patient 1’s Family Member had filed a complaint alleging Patient 1 got bruises from the range of motion exercises performed by LVN 1. LVN 1 further stated she was asked by the HHA to provide an email statement of her interactions at Patient 1’s home for that day, and LVN 1 stated she did send her statement. During a review Patient 1’s record titled, Nursing Flow sheet, dated 10/12/2024, indicated an electronic signature from LVN 1. Patient 1’s Nursing Flow sheet had documented evidence indicating at “11:00”, LVN 1 assisted Patient 1 with passive range of motion exercises to bilateral upper extremities, and at “13:00” LVN 1 also assisted Patient 1 with passive range of motion exercises to all four extremities, documented that Patient 1 tolerated it well. There is no documented evidence on Patient 1’s Nursing flow sheet of LVN 1 stopping range of motion exercises per Patient 1’s Family Request. During a review of the HHA’s Policy and Procedure (P&P) titled, Identifying and Reporting possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation, with a revised date of February 2024, indicated, any agency Staff will immediately report an assessment of patient’s condition which might indicate exploitation, abuse or neglect to the director of clinical services, who will assign a supervisor to assess the patient for abuse, neglect and/or exploitation.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) staff failed to report immediately allegation of staff’s physical abuse and/or neglect for one of ten sampled patients (Patient 1) to the appropriate authority in accordance with the State law. The deficient practice resulted in the delay of the HHA staff, and individuals legally responsible to report suspicion of physical abuse and/or neglect to appropriate State authorities jeopardizing the health and safety of the patient. During a review of Patient 1’s record titled, “Patient Demographics” undated, indicated a Start of Care (SOC) date of 10/5/2022, with a primary diagnosis of Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a long-term condition that results in the inability to effectively exchange carbon dioxide and oxygen, and causes low oxygen levels or high carbon dioxide levels in the body). During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care” (a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for the certification period of 9/24/2024 to 11/22/2024, indicated Patient 1 was to have in home skilled nursing care from 240 hours to 378.67 hours per month. During an interview on 10/29/2024 at 12:20 pm., with the Director of Patient Care Services (DCPS) stated, the agency had received a grievance from Patient 1’s Family Member of alleged abuse, stating that Patient 1 obtained bruises from the Range of Motion (ROM) exercises performed by the Licensed Vocational Nurse 1 (LVN 1) on 10/12/2024 home visit. The DPCS stated the complaint was received on 10/18/2024. The DPCS stated the HHA did the incident report at the time the incident was reported, statements were gathered from both parties and LVN 1 was removed from Patient 1’s case. The DPCS stated she interviewed LVN 1 over the phone and LVN 1 stated she did range of motion exercises on Patient 1 and was never asked to stop the ROM exercises by Patient 1’s Family Member, did not have any arguments with Patient 1’s Family Member and was not aware of Patient 1 having bruises. The DPCS stated the incident was not reported to the department of health or other appropriate authorities because after reviewing email statements from LVN 1 and Patient 1 Family Member and the pictures of Patient 1’s bruises, she did not find the incident to be abuse, as Patient 1’s Family Member did not say it was abuse. The DPCS stated she did not send a nurse to Patient 1’s home to assess Patient 1 after completing the incident report, stated the investigation was based on review of email statements and pictures of Patient 1’s bruises. The DPCS further stated LVN 1 left the HHA shortly after due to not having enough working hours. The DPCS stated allegations of abuse should be reported to appropriate authorities within 24 hours. During a concurrent interview and record review on 10/29/2024 at 12:36 pm., with the Director of Patient Care Services Designee (DPCSD), Incident report for Patient 1, dated 10/12/2024 was reviewed. The incident report for Patient 1 indicated that per the patient caregiver, the skilled nurse completed passive range of motion on Patient 1, used excessive force causing mild bruising on bilateral lower extremities, and the documented corrective actions was skilled nurse removed off the case. The incident report also indicated in the illustration diagram an “I” for injury to right and left top of foot. The incident report for Patient 1 further indicated a signature of person completing the report from Registered Nurse 1 (RN 1). The DPCSD stated RN 1 completed the incident report and the DPCS interviewed LVN 1, and both parties were asked to submit an email statement of the incident. The DPCSD stated the reported incident with Patient 1 was not reported to other appropriate authorities. The DPCSD stated the investigation of the incident with Patient 1 consisted of review of interview and email statements from Patient 1’s Family Member , LVN 1, and photos of Patient 1’s bruises. During an interview on 10/29/2024 at 1:32 pm., with RN 1 stated, she was contacted by Patient 1’s Family Member on 10/18/2024 via text message about the incident that occurred on 10/12/2024, and she reached out to him via phone call that same day. RN 1 stated Patient 1’s Family Member stated the exercises that LVN 1 performed made Patient 1 uncomfortable and told LVN 1 not to use too much force during the exercises. RN 1 asked Patient 1’s Family Member to send an email statement to the Home Health Agency (HHA), as to what happened that day, along with any pictures of Patient 1’s bruises. RN 1 stated she completed the incident report for Patient 1 on 10/18/2024 the day it was reported to her, and next went through the chain of command, communicating this with the DPCS. RN 1 stated the DPCS interviewed LVN 1 and requested to send an email statement to the HHA of what occurred on 10/12/2024 with Patient 1. RN 1 stated she received the email statement with pictures, from Patient 1’s Family Member on 10/21/2024, and received the email statement from LVN 1 on 10/22/2024. RN 1 stated she did not go to Patient 1’s home to assess the patient after receiving the report of the incident, and no other nurse was sent to assess Patient 1. RN 1 further stated once the incident report was completed, LVN 1 was removed off Patient 1’s case. RN 1 stated the incident was not reported to other appropriate authorities, like department of public health. RN 1 stated, she did inform Patient 1’s Family Member that the HHA was investigating the incident and LVN 1 was removed off the case. During a review of the HHA’s Policy and Procedure (P&P) titled, Identifying and Reporting possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation, with a revised date of February 2024, indicated, any agency staff are to report incidences of mistreatment, neglect, verbal, mental, sexual and/or physical abuse, including injuries of unknown sources to the agency and to appropriate authorities immediately within 24 hours.”