Gracelight Home Health

“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: The Agency failed to ensure that the Condition of Participation: G 640 Quality Assessment and Performance Improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the facility failed to create and implement a plan for the monitoring, evaluation, and interpretation of quality indicator data (data or information collected by the facility regarding quality measures used in order to identify areas of improvement, analyze contributing factors, and implement interventions to improve patient quality of care) in the design of its Quality Assessment and Process Improvement (QAPI – is a data driven proactive approach to quality improvement) program, in a universe of 489 patients. (Refer to G 644). 2. Based on interview and record review, the facility failed to ensure as part of the Quality Assessment and Process Improvement (QAPI) program, an infection control program was created and implemented when the facility had no formal process for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. (Refer to G 642) 3. Based on interview and record review, the facility failed to ensure as a part of the Quality Assessment and Process Improvement (QAPI) program, a process was created and implemented for the tracking and investigation of adverse patient events (events that are negative and unexpected, impact a patient’s plan of care, and have the potential to cause a decline in a patient’s condition), analyze their causes, and implement preventive actions (Refer to G654) The cumulative effect of these systemic practices resulted in the potential to cause problems in health outcomes, patient safety, and quality of care, to go unrecognized and unaddressed. And the potential for the agency to provide inferior care and services to its patients.”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G 680 484.70: Infection prevention and control was in compliance when: 1. Based on interview and record review, the facility failed to maintain an infection control program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, in a universe of 489 patients. (Refer to G 684) 2. Based on observation, interview, and record review, the facility failed to ensure patient medical supplies were appropriate for use when multiple supplies were expired, not removed from the storage agrea, and were available for use on patients. (Refer to G 682) The cumulative effect of these systemic practices had the potential to result in infections to go unrecognized and unaddressed and for medical supply sterility and quality to be compromised.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: The agency failed to ensure the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance when: Based on interview, and record review, the facility failed to ensure its governing body exercised operational oversight of the facility when: 1a) The Governing body did not ensure the Quality Assurance and Performance Improvement (QAPI - is a data driven and proactive approach to quality improvement) program created and implemented a plan for the monitoring, evaluation, and interpretation of quality indicator data (data or information collected by the facility regarding quality measures used in order to identify areas of improvement, analyze contributing factors, and implement interventions in order to improve patient quality of care) in the design of its program. (Refer to G 942). 1b) The Governing body did not ensure an infection control program was created and implemented when the facility had no formal process for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases and the facility’s Quality Assurance and Process Improvement program did not incorporate Infection control as specified in the facility’s policies and procedures.(Refer to G 942) 2) The governing body failed to ensure one of its members (Director of Nursing – DON) was oriented in her responsibilities in improving organizational performance and completed a conflict of interest disclosure (disclosure of any transactions with the organization that would result in any benefit to themselves, their immediate families, or any entity in which they hold a significant financial ownership or other interests) as specified in the facility’s policies and procedures. (Refer to G942) The cumulative effect of these systemic practices resulted in increased risk of infections, the facility’s inability to identify and address quality of care areas needing improvement, and for a member of the governing body to be uninformed and/or unfamiliar regarding overall functions, purpose, and responsibilities of the governing body in relation to oversight of the facility and the facility’s bylaws and policies and procedures.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on interview, and record review, the facility failed to develop and maintain an emergency preparedness plan when: 1) Contact information for local, state, federal, tribal and regional emergency preparedness officials were not available as part of the emergency preparedness plan as specified in the facility’s policies and procedures. 2) The Administrator (individual responsible for the creation and implementation of the emergency preparedness program) was not familiar with and did not have contact information for ESP 8 (Emergency Support Function 8 – coordinates the federal response in support of emergency triage, prehospital treatment, patient tracking, and distribution. This effort is coordinated with Federal, State, tribal, territorial and local emergency medical services officials). These failures had the potential to result in an uncoordinated emergency preparedness response and a delay in the communication between the facility and local, state, and/or federal emergency preparedness officials and (associated agencies) which would place the health and safety of all 489 patients at risk during an emergency. Findings: 1) During an interview on June 24, 2024, at 10:25 AM, with the Alternate Administrator (Alt ADMIN), the Alt ADMIN stated he was the individual responsible for the facility’s emergency preparedness plan. During a review of the facility’s “Emergency Action Plan 2024,” dated 2024. The plan indicated, “Tab 9 – Notification Call list…Community Resources Call Protocol…During an emergency, [name of Alt ADMIN] Alt. Administrator is responsible for contacting resources…” During a concurrent interview and record review on June 27, 2024, at 9:30 AM, with the Alt ADMIN, the Alt ADMIN stated the facility maintains contact numbers including local, state, and federal emergency preparedness officials and other resources and information for who to contact on tab “8” of the facility’s emergency preparedness plan. The facility’s emergency preparedness plan titled, “Emergency Action Plan 2024,” dated April 10, 2024, was reviewed. The emergency plan indicated, “Purpose: To describe the actions to be taken in an emergency or exercise to make sure that the clients, staff and visitors of this organization are kept safe from harm. The safety and well-being of the clients and staff take first priority over all other considerations…Coordination…b. During activation for an incident or exercise, communications with State, regional and local authorities can be made by contacting authorities listed in TAB 8…III. Communications…External…C. This EOP [Emergency Operations Plan] contains a list of all Parish and state and local emergency management persons that should be notified at TAB 8…” Tab 8 was then reviewed but did not indicate any contact information for state, regional, parish, or local emergency preparedness authorities. The ADMIN stated TAB 8 of the facility’s EOP plan needed to be updated and he was not aware it didn’t include local, state, regional contact numbers. During a review of the facility’s policy and procedure titled, “Planning Process-Before an Emergency,” revised April 2018, the policy indicated, “…2. Staff will work with regional or county emergency management planning agencies, where available, in: …b. Defining organization’s role in relation to the community-wide emergency management program, use of volunteers, other emergency staff, including state or federally-designated health care professionals to address the organization’s surge needs…Communication Plan. The organization will maintain an emergency preparedness communication plan that complies with federal, state, and local laws and is reviewed and updated annually. The plan includes the following:…2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff…” 2. During a concurrent interview and record review on June 27, 2024, at 9:48 AM, with the Alternate Administrator (Alt ADMIN), the facility’s emergency preparedness plan titled, “Emergency Action Plan 2024,” dated April 10, 2024, was reviewed. The plan indicated, “…B. Patients and staff in the office or field will be tracked (insert method of tracking, such as written or typed list, tracking program, etc.) or by using the ESF 8 Portal at Risk Registry…” The Alt ADMIN stated he did not know what the ESF 8 Portal at Risk Registry was and did not have contact information for it. During continued concurrent interview and record review on June 27, 2024, at 10:33 AM, with the Alt ADMIN, the emergency preparedness plan titled “Emergency Action Plan 2024,” dated April 10, 2024, was reviewed. The plan indicated, “…Surge Capacity and Shared Resources…A. based on staffing and active cases, this agency may be available to surge to accept patients from other agencies requiring like services. The ESF 8 Home Care DRC will be notified of surge capabilities…Requesting Assistance…A. Should the Agency need resources, assistance should be requested as follows:…b. from the ESF 8 Regional representative(s). The ESF 8 regional representatives are the Office of Public Health Emergency Response Coordinator (PHERC) and the Designated Regional Coordinators (ADRC and DRCs). These representatives are listed on TAB 8. They work with the Parishes and State to obtain assistance for facilities during and following emergencies…” TAB 8 was reviewed and did not include any contact information for ESF representatives, PHERC, ADRC and/or DRC representatives. The Alt ADMIN stated he did not know what ESF 8 was or what it meant and stated the contact information for ESF 8 representatives and designated regional coordinators were not listed on TAB 8 and that it was an oversight. The Alt ADMIN further stated the contact information was not included anywhere else in the emergency preparedness plan. During a review of the facility’s policy and procedure titled, ““Planning Process-Before an Emergency,” revised April 2018, the policy indicated, “…2. Staff will work with regional or county emergency management planning agencies, where available, in: …b. Defining organization’s role in relation to the community-wide emergency management program, use of volunteers, other emergency staff, including state or federally-designated health care professionals to address the organization’s surge needs…Communication Plan. The organization will maintain an emergency preparedness communication plan that complies with federal, state, and local laws and is reviewed and updated annually. The plan includes the following:…2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff. B. Other sources of assistance…””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview, and record review, the facility failed to ensure it implemented an infection control program when the facility had no formal process for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases and the facility’s Quality Assurance and Process Improvement program (QAPI - is a data driven and proactive approach to quality improvement) did not incorporate Infection control as specified in the facility’s policies and procedures. This failure had the potential to jeopardize the health and safety of all 489 patients in which the facility provided services as a result of an increased risk for the transmission of infections and communicable diseases. Findings: During an interview on June 27, 2024, at 11:40 AM, with the Alternate Administrator ( Alt ADMIN), the Alt ADMIN stated the facility ran a monthly report titled, “High Tech Patients,” which showed the patients receiving home health services that were at increased risk for infections due to the patients having either indwelling urinary catheters (a catheter which drains urine from your bladder into a bag outside your body, wounds, tracheostomies, and other devices which made them at risk for infection. The Alt ADMIN stated the facility ran the reports monthly, but the data was only printed on a report and was not reviewed for trends, monitoring, or analyzed for infection control purposes. The Alt ADMIN further stated the facility’s infection control program needed improvement. During an interview on June 27, 2024, at 11:45 AM, with the Alt ADMIN, the Alt ADMIN stated the facility did not have a process in place for investigating infections or tracking, trending, and analyzing information regarding to infection control. The ADMIN further stated during the facilities QAPI meetings, the QAPI committee did not analyze or discuss any data regarding infection control. During an interview on June 27, 2024, at 2:26 PM, with the Director of Nursing (DON), the DON stated she was a part of the QAPI committee and there were no specific reports or data tracked, reviewed and/or analyzed in relation to infection control. During a review of the facility’s QAPI binder (a binder which contains meeting minutes from the facility’s QAPI meetings), undated, the binder was reviewed and did not contain data or information collected and subsequently reviewed as a part of an active infection control program. During an interview on June 28, 2024, at 11:05 AM, with the Alt ADMIN, the Alt ADMIN stated the facility was working on implementing a process for improving their infection control program in QAPI and still needed to come up with a method for quantifying, trending, and charting data in relation to infection control, but had not yet done so. During a review of the facility’s policy and procedure titled, “Infection Control Plan,” dated November 2023, the policy indicated, “Purpose – To delineate an infection control plan to meet the following goals: 1. Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections…4. Provide for surveillance systems to track the occurrence and transmission of infections…Policy – [name of facility] is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/controls, and reporting procedures. To determine the effectiveness of the infection control plan, [name of facility] will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program…7. Home Health: Infection control activities and outcomes will be part of the organization’s QAPI program.” During a review of the facility’s policy and procedure titled, “Improving Organizational Performance,” dated April 2017, the policy indicated, “To establish a performance improvement framework, which integrates activities to improve organizational performance, improve patient outcomes, improve patient safety, and reduce the risks for acquisition and transmission of infections. Policy – Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service…””

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview, and record review, the facility failed to create and implement a plan for the monitoring, evaluation, and interpretation of quality indicator data (data or information collected by the facility regarding quality measures used in order to identify areas of improvement, analyze contributing factors, and implement interventions in order to improve patient quality of care) in the design of its program. This failure had the potential to impact the health and safety of all 489 patients receiving services from the facility as a result of the facility’s inability to identify and address quality of care areas needing improvement. Findings: During an interview on June 27, 2024, at 2:16 PM, with the Alternate Administrator (Alt ADMIN), the Alt ADMIN stated the facility printed reports called “Outcome and Assessment Information Set (OASIS- a key component of the Centers for Medicare and Medicaid (CMS) partnership with the home care industry to foster and monitor improved home health care outcomes).” The Alt ADMIN further stated the facility just “prints the CMS OASIS reports and just files them.” The Alt ADMIN stated the facility did not yet have a process to review and analyze the reports and that the Office Manager (Off Mgr) could locate the reports. During a concurrent interview and record review on June 27, 2024, at 2:34 PM, with the Office Manager (Off Mgr), and the Administrator (ADMIN), the Off Mgr stated she was unable to find the previously printed OASIS reports in which the Alt ADMIN stated were filed. The ADMIN stated if they had run the reports, they would be in the Binder titled, “Oasis Transmission Records.” The facility binder titled, “Oasis Transmission Records,” undated, was reviewed. The binder included one OASIS quality measure report dated April 25, 2024. There were no other OASIS quality measure reports found. During an interview on June 28, 2024, at 11:05 AM, with the Alt ADMIN, the Alt ADMIN stated the facility had chosen patient re-hospitalizations and medication errors as other quality indicators to track but the facility needed “to work on coming up with a process to quantify, trend, chart, and analyze the information.” During an interview on June 28, 2024, at 11:32 AM, with the Director of Nursing (DON), the DON stated in regards to quality indicators, the facility collected data regarding patient re-hospitalizations but did not yet have a formalized process to analyze and understand the data or interpret why rehospitalizations were occurring or contributing factors. During an interview on June 28, 2024, at 11:42 AM, with the Administrator (ADMIN), the ADMIN stated the facility did not have any reports or quality indicator data that was reviewed as a part of Quality Assurance and Process Improvement (QAPI- is a data driven and proactive approach to quality improvement) and that the facility still needed to develop the process. During a review of the facility’s policy and procedure titled, “Sample Quality Assessment and Performance Improvement (QAPI) Plan,” dated November 2023, the policy indicated, “Purpose – The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities….Objectives – To show measurable improvement in indicators that demonstrate an improvement in patient outcomes – To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, home health services and operations – to collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement…The effectiveness of any action will be assessed through a process that measures whether the performance expectations outlined in the action plan have been met. This may require additional data collection and analysis. Statistical analysis will be used in assessing performance outcomes…””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure patient medical supplies were appropriate for use when multiple supplies were expired, not removed from the storage area, and were available for use on patients. This failure resulted in jeopardizing the supplies sterility (infection control) and integrity (quality control) of the medical supplies available for use (as needed) for all 489 patients on service with the agency. Findings: During a concurrent observation and interview on June 25, 2024, at 1:30 PM, with the Office Manager (OMGR) in the facilities supply room, the OMGR stated she was the individual responsible to ensure the supplies stored in the facility’s supply room were not expired and that expired supplies were removed from the room. The OMGR further stated it was important to ensure expired supplies were removed from the supply room so they were not sent out and used on a patient. The OMGR stated the supplies in the room were ready for use on patients as needed. Two clear totes were observed in the supply room and the OMGR stated the totes were intravenous supplies which were ready for use. The contents of both totes were reviewed and the following was identified to be expired: -Sixteen (16) Rate Flow Regulator Intravenous (IV) sets (a tubing set used to administer fluids and medications into the veins) were expired; four (4) expired December 24, 2023, two (2) expired October 16, 2022, two (2) expired June 10, 2023, two (2) expired December 17, 2023, one (1) expired November 27, 2020, one (1) expired March 4, 2024, one (1) expired October 31, 2023, one (1) expired June 25, 2021, one (1) expired December 18, 2023, and one (1) expired June 25, 2022. -six (6) [brand name] infusion administration sets (a tubing set used to administer fluids and medications into the veins) were expired; three (3) expired April 20, 2021, two (2) expired August 4, 2021, and one (1) expired August 6, 2021. -one (1) [brand name] High Volume Administration set (a tubing set to be used with an infusion pump to administer fluids and medications into the veins) was expired on December 2, 2022. -one (1) Intravenous administration set with GVS easydrop flow regulator (a tubing set used to administer fluids and medications into the veins) was expired on April 20, 2023. -one (1) 12 inch (in – unit of measure) extension set, male/female luer lock with pinch clamp (an extension tubing set which connects to an Intravenous catheter) was expired on September 2021. -one (1) 92 inch flow regulator IV set with drip chamber (a tubing set used to administer fluids and medications) expired on September 24, 2023. -two (2) Continu-flo solution set with regulator, 96 inch luer activated valves (a tubing set used to administer fluids and medications). The OMGR reviewed all contents of the two clear totes and agreed there were multiple expired supplies. The OMGR stated she did not know why the expired supplies were in the supply room. During an interview on June 27, 2024, at 9:08 AM, with the Director of Nursing (DON), the DON stated she was recently made aware there were expired supplies in the supply room. The DON further stated all expired supplies were supposed to be removed from the supply room and discarded. During a review of the facility’s policy and procedure titled, “Environmental Safety – Office,” dated November 2023, the policy indicated, “…4. All areas of the organization, including passageways, storerooms, and service rooms, will be kept clean and orderly and in a sanitary condition.””

“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 facility failed to ensure it implemented an infection control program when the facility had not created a process for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases. This failure had the potential to jeopardize the health and safety of all 489 patients in which the facility provided services as a result of an increased risk for the transmission of infections and communicable diseases. Findings: During an interview on June 27, 2024, at 11:40 AM, with the Alternate Administrator ( Alt ADMIN), the Alt ADMIN stated the facility ran a monthly report titled, “High Tech Patients,” which showed the patients receiving home health services that were at increased risk for infections due to the patients having either indwelling urinary catheters (a catheter which drains urine from your bladder into a bag outside your body, wounds, tracheostomies, and other devices which made them at risk for infection. The Alt ADMIN stated the facility ran the reports monthly, but the data was only printed on a report and was not reviewed for trends, monitoring, or analyzed for infection control purposes. The Alt ADMIN further stated the facility’s infection control program needed improvement. During an interview on June 27, 2024, at 11:45 AM, with the Alt ADMIN, the Alt ADMIN stated the facility did not have a process in place for investigating infections or tracking, trending, and analyzing information regarding to infection control. During an interview on June 27, 2024, at 2:26 PM, with the Director of Nursing (DON), the DON stated the there were no specific reports or data tracked, reviewed and/or analyzed in relation to infection control. During an interview on June 28, 2024, at 11:05 AM, with the Alt ADMIN, the Alt ADMIN stated the facility was working on implementing a process for improving their infection control program and still needed to come up with a method for quantifying, trending, and charting data in relation to infection control, but had not yet done so. During a review of the facility’s policy and procedure titled, “Infection Control Plan,” dated November 2023, the policy indicated, “Purpose – To delineate an infection control plan to meet the following goals: 1. Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections…4. Provide for surveillance systems to track the occurrence and transmission of infections…Policy – [name of facility] is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/controls, and reporting procedures. To determine the effectiveness of the infection control plan, [name of facility] will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program… During a review of the facility’s policy and procedure titled, “Improving Organizational Performance,” dated April 2017, the policy indicated, “To establish a performance improvement framework, which integrates activities to improve organizational performance, improve patient outcomes, improve patient safety, and reduce the risks for acquisition and transmission of infections. Policy – Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service…””

“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 observation, interview, and record review, the facility failed to ensure their personnel development policy was being implemented for six of fifteen sampled home health aides (HHA- HHA 1, 2, 3, 4, 5, 6) when six HHAs did not have twelve hours of in-service education in twelve months for the year 2023. This failure had the potential for the home health aides to not have the in-service education which could affect patient care. Findings: 1. During a review of HHA 1’s “In-Service” binder, dated 2023, the “In-Service” binder indicated HHA 1 was missing five hours of in-service education for the months of January, April, May, August, and September 2023. During an interview on June 27, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON validated the five missing hours for HHA 1 in 2023. 2. During a review of HHA 2’s “In-Service” binder, dated 2023, the “In-Service” binder indicated HHA 2 was missing two hours of in-service education for the months of January and February 2023. During an interview on June 27, 2024, at 2:31 PM, with the DON, the DON validated the two missing hours for HHA 2 in 2023. 3. During a review of HHA 3’s “In-Service” binder, dated 2023, the “In-Service” binder indicated HHA 3 was missing four hours of in-service education for the months of July, August, September, and October 2023. During an interview on June 27, 2024, at 2:32 PM, with the DON, the DON validated the four missing hours for HHA 3 in 2023. 4. During a review of HHA 4’s “In-Service” binder, dated 2023, the “In-Service” binder indicated HHA 4 was missing four hours of in-service education for the months of August, October, November and December 2023. During an interview on June 27, 2024, at 2:33 PM, with the DON, the DON validated the four missing hours for HHA 4 in 2023. 5. During a review of HHA 5’s “In-Service” binder, dated 2023, the “In-Service” binder indicated HHA 5 was missing two hours of in-service education for the months of September and December 2023. During an interview on June 27, 2024, at 2:34 PM, with the DON, the DON validated the two missing hours for HHA 5 in 2023. 6. During a review of HHA 6’s “In-Service” binder, dated 2023, the “In-Service” binder indicated HHA 6 was missing two hours of in-service education for the months of January and September 2023. During an interview on June 27, 2024, at 2:35 PM, with the DON validated the two missing hours for HHA 6 in 2023. During a concurrent interview and record review on June 27, 2024, at 2:51 PM, with the DON, the facility’s policy and procedure (P&P) titled, “Personnel Development” dated revised November 2023 was reviewed. The P&P indicated, “…to ensure ongoing training and development for all personnel to maintain competence in assigned duties …9. In addition, clinical personnel must attend a minimum of the following: … B. Home health aides will attend 12 hours of inservice education during each 12-month period.” The DON stated the P&P was not followed.”

“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 observation, interview, and record review, the facility failed to ensure its license granted by the California Department of Public Health was displayed in a conspicuous area within the agency as specified as a requirement in Title 22 for home health agencies (HHAs). This failure resulted in the facility to not have the required posted state license available for public viewing as specified in title 22 (regulations for home health agencies). Findings: During a concurrent observation and interview on June 24, 2024, at 11:25 AM, with the Alternate Administrator (Alt ADMIN), the facility did not have their state license posted in an a conspicuous location and was not seen anywhere in the common lobby of the facility. The Alt ADMIN acknowledged the facility only had their business license posted. During an interview on June 27, 2024, at 2:51 PM, with the Administrator (ADMIN), the ADMIN stated she was aware the state license was not posted in an a conspicuous area within the facility and states it used to be posted in the main lobby area of the facility but it was taken down a couple months ago and was never put back up. During an interview on June 27, 2024, at 1:39 PM, with the Office Manager (OMGR), the OMGR stated she was the individual to request facility policies and procedures from. The OMGR further stated the facility did not have a policy regarding the posting of licenses. During a review of the California Code of Regulations (CCR); Title 22 – Social Security; Division 5 – Licensing and Certification of Health Facilities, Home Health Agencies, Clinics and Referral Agencies; Chapter 6- Home Health Agencies; Article 2- License; 74677 -Availability of License,” database dated June 28, 2024, the CCR indicated, “The license, or a true copy thereof, shall be conspicuously posted in a location accessible to public view in the main business area.””

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on interview, and record review, the facility failed to ensure its governing body exercised operational oversight of the facility when: 1a) The Governing body did not ensure the Quality Assurance and Performance Improvement (QAPI - is a data driven and proactive approach to quality improvement) program created and implemented a plan for the monitoring, evaluation, and interpretation of quality indicator data (data or information collected by the facility regarding quality measures used in order to identify areas of improvement, analyze contributing factors, and implement interventions in order to improve patient quality of care) in the design of its program. 1b) The Governing body did not ensure an infection control program was created and implemented when the facility had no formal process for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases and the facility’s Quality Assurance and Process Improvement program did not incorporate Infection control as specified in the facility’s policies and procedures. These failures had the potential to jeopardize the health and safety of all 489 patients in which the facility provided services as a result of an increased risk for the transmission of infections and communicable diseases and the facility’s inability to identify and address quality of care areas needing improvement. 2) The governing body failed to ensure one of its members (Director of Nursing – DON) was oriented in her responsibilities in improving organizational performance and completed a conflict of interest disclosure (disclosure of any transactions with the organization that would result in any benefit to themselves, their immediate families, or any entity in which they hold a significant financial ownership or other interests) as specified in the facility’s policies and procedures. This failure had the potential for a member of the governing body to be uninformed and/or unfamiliar regarding overall functions, purpose, and responsibilities of the governing body in relation to oversight of the facility and the facility’s bylaws and policies and procedures. Findings: 1a) During an interview on June 27, 2024, at 2:16 PM, with the Alternate Administrator (Alt ADMIN), the Alt ADMIN stated the facility printed reports called “Outcome and Assessment Information Set (OASIS- a key component of the Centers for Medicare and Medicaid (CMS) partnership with the home care industry to foster and monitor improved home health care outcomes).” The Alt ADMIN further stated the facility just “prints the CMS OASIS reports and just files them.” The Alt ADMIN stated the facility did not yet have a process to review and analyze the reports and that the Office Manager (Off Mgr) could locate the reports. During a concurrent interview and record review on June 27, 2024, at 2:34 PM, with the Office Manager (Off Mgr), and the Administrator (ADMIN), the Off Mgr stated she was unable to find the previously printed OASIS reports in which the Alt ADMIN stated were filed. The ADMIN stated if they had run the reports, they would be in the Binder titled, “Oasis Transmission Records.” The facility binder titled, “Oasis Transmission Records,” undated, was reviewed. The binder included one OASIS quality measure report dated April 25, 2024. There were no other OASIS quality measure reports found. During an interview on June 28, 2024, at 11:05 AM, with the Alt ADMIN, the Alt ADMIN stated the facility had chosen patient re-hospitalizations and medication errors as other quality indicators to track but the facility needed “to work on coming up with a process to quantify, trend, chart, and analyze the information.” During an interview on June 28, 2024, at 11:32 AM, with the Director of Nursing (DON), the DON stated in regards to quality indicators, the facility collected data regarding patient re-hospitalizations but did not yet have a formalized process to analyze and understand the data or interpret why rehospitalizations were occurring or contributing factors. During an interview on June 28, 2024, at 11:42 AM, with the Administrator (ADMIN), the ADMIN stated the facility did not have any reports or quality indicator data that was reviewed as a part of Quality Assurance and Process Improvement (QAPI- is a data driven and proactive approach to quality improvement) and that the facility still needed to develop the process. During a review of the facility’s policy and procedure titled, “Sample Quality Assessment and Performance Improvement (QAPI) Plan,” dated November 2023, the policy indicated, “Purpose – The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities….Objectives – To show measurable improvement in indicators that demonstrate an improvement in patient outcomes – To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, home health services and operations – to collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement…The effectiveness of any action will be assessed through a process that measures whether the performance expectations outlined in the action plan have been met. This may require additional data collection and analysis. Statistical analysis will be used in assessing performance outcomes…The Governing Body is ultimately responsible for ensuring that the performance improvement program is defined, implemented and maintained…” During a review of the facility’s policy and procedure titled, “Improving Organizational Performance,” dated April 2017, the policy indicated, “To establish a performance improvement framework, which integrates activities to improve organizational performance, improve patient outcomes, improve patient safety, and reduce the risks for acquisition and transmission of infections. Policy – Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service…The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented and maintained, and is evaluated annually…Procedure…1. Senior management with Governing Body oversight will: …B. Set expectations for performance improvement and manage processes to improve organizational performance…D. Adopt a structured framework for performance improvement. The problem solving approach will stress the interrelationship of quality services provided, management activities, and sound business practices as applicable to the organization’s: …9. Quality indicators 10. Data collection and analysis (measured and documented in a systematic and retrievable way)…4. Trends Identified through performance improvement measurement and analysis will be reported to the Governing Body on a quarterly basis…” 1b) During an interview on June 27, 2024, at 11:40 AM, with the Alternate Administrator ( Alt ADMIN), the Alt ADMIN stated the facility ran a monthly report titled, “High Tech Patients,” which showed the patients receiving home health services that were at increased risk for infections due to the patients having either indwelling urinary catheters (a catheter which drains urine from your bladder into a bag outside your body, wounds, tracheostomies, and other devices which made them at risk for infection. The Alt ADMIN stated the facility ran the reports monthly, but the data was only printed on a report and was not reviewed for trends, monitoring, or analyzed for infection control purposes. The Alt ADMIN further stated the facility’s infection control program needed improvement. During an interview on June 27, 2024, at 11:45 AM, with the Alt ADMIN, the Alt ADMIN stated the facility did not have a process in place for investigating infections or tracking, trending, and analyzing information regarding to infection control. The ADMIN further stated during the facilities QAPI meetings, the QAPI committee did not analyze or discuss any data regarding infection control. During an interview on June 27, 2024, at 2:26 PM, with the Director of Nursing (DON), the DON stated she was a part of the QAPI committee and there were no specific reports or data tracked, reviewed and/or analyzed in relation to infection control. During a review of the facility’s QAPI binder (a binder which contains meeting minutes from the facility’s QAPI meetings), undated, the binder was reviewed and did not contain data or information collected and subsequently reviewed as a part of an active infection control program. During an interview on June 28, 2024, at 11:05 AM, with the Alt ADMIN, the Alt ADMIN stated the facility was working on implementing a process for improving their infection control program in QAPI and still needed to come up with a method for quantifying, trending, and charting data in relation to infection control, but had not yet done so. During a review of the facility’s policy and procedure titled, “Infection Control Plan,” dated November 2023, the policy indicated, “Purpose – To delineate an infection control plan to meet the following goals: 1. Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections…4. Provide for surveillance systems to track the occurrence and transmission of infections…Policy – [name of facility] is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/controls, and reporting procedures. To determine the effectiveness of the infection control plan, [name of facility] will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program…7. Home Health: Infection control activities and outcomes will be part of the organization’s QAPI program.” During a review of the facility’s policy and procedure titled, “Improving Organizational Performance,” dated April 2017, the policy indicated, “To establish a performance improvement framework, which integrates activities to improve organizational performance, improve patient outcomes, improve patient safety, and reduce the risks for acquisition and transmission of infections. Policy – Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service…” 2) During a concurrent interview and record review on June 28, 2024, at 9:30 AM, with the Alternate Administrator (Alt ADMIN), the Alt ADMIN stated the facility’s governing body consisted of the Administrator (ADMIN), the Alt ADMIN, and the Director of Nursing (DON) as indicated on the first page of the “Governing Body Minutes” binder. The “Governing Body Minutes” binder, undated was reviewed and the first page indicated, “Policy and Procedures Manual Approved by the Governing Board Effective 4/05/2024…” Job titles and names of the ADMIN, ALT ADMIN, and DON were then listed. During an interview on June 28, 2024, at 9:56 AM, with the DON, the DON stated she was part of the governing body and has been so since April 2024. The DON further stated she was a part of the QAPI program. The DON stated she was informed she was on the governing body but stated she did not recall doing any orientation checklist and did not recall having any specific training regarding the facility’s governing body and also did not recall completing a conflict of interest disclosure form. During a review of the facility binder titled, “Governing Body Minutes” binder, undated, the binder included a documented training checklist titled, “Governing Body Orientation Checklist,” which was signed and dated by both the ADMIN and the Alt ADMIN. However, there was no training orientation checklist completed by the DON. During an interview on June 28, 2024, at 10:00 AM, with the Alt ADMIN, the Alt ADMIN stated the DON was part of the governing body and that the facility had not conducted orientation training or completed an orientation checklist for her. The Alt ADMIN further stated the DON had not completed the facility’s conflict of interest disclosure form as indicated in the facilities policies and procedures. When asked to see the meeting minutes or documented evidence approving the DON as part of the governing body, the Alt ADMIN stated there were none. During a review of the facility’s policy and procedure titled, “Governing Body,” dated April 2017, the policy indicated, “Purpose -To outline the roles and responsibilities of the Governing Body. Policy – the Governing Body will assume full legal authority, responsibility and accountability for the operation of Organization’s Name [sic]. The Governing Body of Organization’s Name [sic] will serve as the governing authority for the home care program, which will function according to Organization’s Name’s [sic] bylaws…17. All new Governing Body members will participate in an orientation program that includes: A. Review of their responsibilities in improving organizational performance B. Review of their responsibilities as defined by the organization bylaws/articles of incorporation 18. Documentation of each member’s orientation will be maintained by the organization. See “Governing Body Orientation Checklist…””

“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 observations, interviews, and record reviews, the facility failed to ensure a review of all medications the patients were taking was conducted (medication reconciliation) for four of seven sampled patients (Patients 1, 2, 4, and 6). This failure resulted in the facility and patients to not have an updated “Plan of Care” (patient treatment plan), or “Medication Profile” (a comprehensive summary of all medications taken by the patient), when compared to the actual medications the patient was taking in the home which may contribute to medication administration errors, discrepancies, or non-compliance with physician’s orders. Findings: 1. A review of Patient 1’s Home Health Certification (a document that gives a summary of patient information), and Plan of Care (a document that provides direction of type of nursing care a patient needs), indicated a start of care date of December 19, 2023, with a certification period of June 16, 2024, to August 14, 2024. Further review indicated Patient 1 had a primary diagnosis of chronic obstructive pulmonary disease (a progressive lung disease). During a home visit on June 25, 2024, at 9:00 AM, with a Physical Therapy Assistant (PTA). Patient 1’s medications bottles were on the dresser in his room where the medications were compared with Patient 1’s most current medication profile (MP). During a concurrent observation and interview, on June 25, 2024, at 9:35 AM, at Patient 1’s home with the PTA, and in presence of Patient 1, an observation of Patient 1’s medication bottles were compared with his (Patient 1’s) most current “Medication Profile” dated, June 24, 2024, and “Plan of Care”, with a certification period of June 16, 2024 through August 14, 2024. The following discrepancies were found: 1a. Patient 1’s home medications (that he is actively taking) included Clonidine HCL (medication used to treat high blood pressure) 0.2 milligrams (mg - unit of measurement) tablet, 1 tab every 8 hours per day. The patient’s medication profile and plan of care indicated Clonidine 0.2 mg 1 tab daily. (discrepancy in frequency). 1b. Patient 1’s home medications (that he is actively taking) included Eliquis (a medication used to lower risk of a blood clot), 5 mg, 1 tab, 2 times daily. The patient’s medication profile and plan of care indicated Eliquis 5g 1 tab daily (discrepancy in frequency). 1c. Famotidine (medication used to treat gastric reflux, heartburn) 20mg, 1 tablet at bedtime. The patient’s medication profile and plan of care indicated, Famotidine Oral Suspension, reconstituted, 40mg/5ml, 5ml at bedtime (discrepancy in dose). 1d. Furosemide (a diuretic medication to treat edema [swelling]) 20 mg, 1 tablet daily. The patient’s medication profile and plan of care indicated Furosemide 20mg 2 times daily (discrepancy in frequency). 1e. Gabapentin (a medication used to treat partial seizures) 300 mg, 1 tablet daily. The patient’s medication profile and plan of care indicated Gabapentin 300 mg, 1 tab 2 times a day (discrepancy in frequency). 1f. Metformin (medication used to treat high blood sugar) 1000 mg, 1 tablet daily. The patient’s medication profile and plan of care indicated Metformin 500 mg, 1 tab 2 times a day (discrepancy in dose and frequency). 1g. Abilify (medication used to treat depression) 30mg, 1 tab daily. The medication is on the patient’s medication profile and plan of care but not in the patient’s home. During a concurrent interview and record review, on June 30, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON acknowledged there were multiple discrepancies when comparing the actual medication’s Patient 1was taking, the medication profile, and the plan of care. DON stated the Registered Nurse was responsible for reconciling Patient 1’s medications. The DON further stated the medication profile, and plan of care should match the medications Patient 1 was taking. During a record review of the facility’s policy and procedure, titled, “Medication Profile”, dated revised November 2023, POLICY: …Medication profiles will be updated for each change to reflect to reflect current medications, new, and/or discontinued medications… A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. DON stated the policy was not followed. 2. A review of Patient 2’s Home Health Certification (a document that gives a summary of patient information), and Plan of Care (a document that provides direction of type of nursing care a patient needs), indicated a start of care date of February 24, 2024, with a certification period of June 23, 2024, to August 21, 2024. Further review indicated Patient 1 had diagnoses which included cellulitis (bacterial skin infection) of unspecified part of limb and type 2 diabetes mellitus (a disease that results in too much sugar in the blood). During a concurrent observation, interview, and record review on June 25, 2024, at 10:10 AM, at Patient 6’s home, with Licensed Vocational Nurse 1 (LVN 1) and Patient 2, observation of Patient 2’s medication bottles (which she was actively taking) were compared with her (Patient 2’s) most current “Medication Profile”, (undated) but with a review date and signature by an RN on June 20, 2024, and “Plan of Care”, with a certification period of June 23, 2024, to August 21, 2024. The following discrepancies were noted: 2a. Patient 2’s home medications (that he was actively taking) included Metformin (medication used to control blood sugar levels) 1000 mg (unit of measure) tablet (tab) daily. The patient’s medication profile and plan of care indicated the medication Metformin dosage was 850 mg (discrepancy in dose) which was to be taken twice a day (discrepancy in the frequency). LVN 1 confirmed the Metformin dose and frequency was discrepant between the medication Patient 2 was taking and what was documented on the plan of care and medication profile. 2b. Patient 2’s home medications (that he was actively taking) included Glipizide (medication used to control blood sugar levels) 10 mg tab, 1 tab by mouth daily. Patient 2’s medication profile and plan of care indicated the Glipizide dose was 5 mg taken once daily (discrepancy in dose). LVN 1 confirmed there was a dose discrepancy between what the patient was taking and what was on the medication profile and plan of care. 2c. Patient 2’s home medications (that he was actively taking) included Losartan Potassium (medication used to treat blood pressure) 100 mg tab, by mouth daily. This medication was not on Patient 2’s medication profile or plan of care. LVN 1 confirmed the medication was not indicated on Patient 2’s medication profile or plan of care. 2d. Patient 2’s home medications (that he was actively taking) included Basaglar Kwikpen Subcutaneous injector (a long acting insulin medication used to help control blood sugar levels) inject 20 units (unit of measure) subcutaneously (beneath the skin), once daily. Patient 2’s medication profile and plan of care indicated, “Basaglar kwikpen subcutaneous…18 units…at bedtime…” (discrepancy in dose). LVN 1 confirmed the medication had a different dose on the Medication profile and plan of care when compared to the actual medication the patient was taking. During continued interview on June 25, 2024, at 10:15 AM, with LVN 1, LVN 1 acknowledged there were multiple discrepancies noted between the medications Patient 2 was taking when compared to the patients medication profile and plan of care. LVN 1 further stated the discrepancies were supposed to be identified when the registered nurse visited the patient and that her responsibility was to ask the patient if there had been any changes to the patients medication regimen upon each visit. During an interview on June 25, 2024, at 10:23 AM, with Patient 2, Patient 2 stated there had not been any changes to his medication regimen within the last two months. During an interview on June 25, 2024, at 12:57 PM, with the Director of Nursing (DON), the DON stated medication reconciliation was important because patients should be taking medications in accordance with their physician’s orders and the home health agency needed to be updated regarding any medication changes. The DON further stated the medication reconciliation process was supposed to be done at the start of care (start date the home health agency provides care to the patient), any time there is a resumption of care, change of status, or recertification. The DON stated the registered nurse performed the medication reconciliation on June 20, 2024 for Patient 2 should have identified and fixed the discrepancies but she did not. The DON stated the RN who performed the review was not available for interview. During a review of the facility’s policy and procedure titled, “Medication Profile,” revised November 2023, the policy indicated, “To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals…Policy…Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…Procedure…2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug interactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy…” 4. A review of Patient 4’s Home Health Certification (a document that gives a summary of patient information), and Plan of Care (a document that provides direction of type of nursing care a patient needs), indicated a start of care date of January 26, 2024, with a certification period of May 25, 2024, to July 23, 2024. Further review indicated Patient 4 had a primary diagnosis of acute on chronic congestive heart disease (when the heart can’t pump enough blood to the body). During a concurrent observation, interview, and record review on June 25, 2024, at 1:00 PM, at Patient 4’s home, with the Licensed Vocational Nurse (LVN), and in the presence of Patient 4, an observation of Patient 4’s medication bottles (which she was actively taking), were compared with her (Patient 4’s) most current “Medication Profile” dated June 24, 2024, and “Plan of Care”, with a certification period of May 25, 2024 through July 23, 2024. The following discrepancies were noted: 4a. Patient 4’s home medications (that she was actively taking) included furosemide (a diuretic medication used to treat edema [swelling]), 40 mg tab, 1 tab 2 times a day. The patient’s medication profile and plan of care indicated Furosemide 40 mg, 1 tab once a day (discrepancy in frequency). 4b. Patient 4’s home medications (that she was actively taking) included Albuterol Inhaler (medication used to prevent and treat shortness of breath), 90 mcg, 2 puffs, 2 times a day. This medication was not on Patient 4’s medication profile or plan of care. 4c. Patient 4’s home medications (that she was actively taking) included Qvar Inhaler (medication used for maintenance treatment for asthma), 40 mcg, 2 puffs, 2 times a day. This medication was not on Patient 4’s medication profile or plan of care. 4d. Patient 4’s home medications (that she was actively taking) included Acetazolamide (diuretic medication used to treat swelling by heart disease), 250 mg, 1 tab daily as needed. This medication was not on Patient 4’s medication profile or plan of care. 4e. Patient 4’s home medications (that she is actively taking) included Ergocalciferol 1.25 mg (5,000 UT), (a dietary supplement), 1 tab weekly. The patient’s medication profile and plan of care indicated Ergocalciferol 1.25 mg, 1 tab once a day (discrepancy in frequency). During a concurrent interview and record review, on June 30, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON acknowledged there were multiple discrepancies when comparing the actual medication’s Patient 1was taking, the medication profile, and the plan of care. DON stated the Registered Nurse was responsible for reconciling Patient 1’s medications. The DON further stated the medication profile, and plan of care should match the medications Patient 1 was taking. During a record review of the facility’s policy and procedure, titled, “Medication Profile”, dated revised November 2023, POLICY: …Medication profiles will be updated for each change to reflect to reflect current medications, new, and/or discontinued medications… A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. DON stated the policy was not followed. 6. A review of Patient 6’s Home Health Certification (a document that gives a summary of patient information), and Plan of Care (a document that provides direction of type of nursing care a patient needs), indicated a start of care date of February 25, 2023, with a certification period of June 15, 2024, to August 13, 2024. Further review indicated Patient 1 had diagnoses which included hypertension (increased blood pressure), and epilepsy (seizure disorder). During a concurrent observation, interview, and record review on June 25, 2024, at 2:55 PM, at Patient 6’s home, with Patient 6’s caregiver, observation of Patient 6’s medication bottles (which she was actively taking) were compared with her (Patient 6’s) most current “Medication Profile”, (undated) but with a review date and signature by an RN on June 13, 2024, and “Plan of Care”, with a certification period of January 14, 2024 through March 13, 2024. The following discrepancies were noted: 6a. Patient 6’s home medications (that she was actively taking) included Levothyroxine (a medication used to treat an underactive thyroid gland) 0.025 milligrams (mg- unit of measure) 1 tablet (tab) by mouth daily. This medication was not on Patient 6’s medication profile or plan of care. 6b. Patient 6’s home medications (that she was actively taking) included Eliquis 2.5 mg tab two times daily. The patient’s medication profile and plan of care indicated the medication was only to be taken at bedtime (discrepancy in the frequency) 6c. Patient 6’s home medications (that she was actively taking) included fluphenazine (antipsychotic medication used to treat schizophrenia and psychotic symptoms such as hallucinations, delusions, and hostility) 1 mg tab, 4 tablets by mouth at bedtime. This medication was not on Patient 6’s medication profile or plan of care. 6d. Patient 6’s home medications (that she was actively taking) included Trihexyphenidyl (a medication used to treat spasms, tremors, and stiffness) 2 mg tab, 1 tab by mouth at bedtime. This medication was not on Patient 6’s medication profile or plan of care. 6e. Patient 6’s home medications did not include aspirin. The patient’s medication profile and plan of care indicated the patient was taking aspirin 81 mg by mouth daily. Patient 6’s caregiver stated he was very familiar with Patient 6’s medications and there had not been any changes to her medications for a year. Patient 6’s caregiver further stated the patient had not been on aspirin for over a year and he did not know why the patients plan of care or medication profile did not have updated information. During a review of the facility’s policy and procedure titled, “Medication Profile,” revised November 2023, the policy indicated, “To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals…Policy…Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…Procedure…2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug interactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy…””

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure their hiring of personnel policy was being implemented for one of nine staff members (Alternative Administrator) when the facility failed to have the Alternative Administrator have an initial physical exam and tuberculosis (TB- an infectious respiratory disease) exam upon hire. This failure had the potential to have an alternative administrator without consistency in hiring documents in their employee file. Findings: During a review of the Alternate Administrator “Employee Files”, the “Employee File” did not contain an initial physical exam. The “Employee File” further did not contain an initial TB exam. During a concurrent interview and record review on June 26, 2024, at 2:45 PM, with Human Resources (HR), the Alternative Administrator’s Employee File was reviewed. The HR stated the Alternative Administrator did not need a physical exam and TB exam. During a concurrent interview and record review on June 27, 2024, at 10:51 AM, with HR, the facility’s policy and procedure (P&P) titled, “Selection/Hiring of Personnel” dated revised November 2023 was reviewed. The P&P indicated, “…to specify the criteria for the recruitment and hiring of personnel to meet the care/service needs of patients … the organization will use a consistent, nondiscriminatory process for the selection of all personnel … 10. An offer of employment will be contingent upon a current physical and TB test/chest x-ray.” The HR stated the policy was not followed.”