Network Providers for Home Health, Inc.

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on document review and interview, the agency failed to ensure the HHA’s emergency preparedness P&P addressed a system of medical documentation that secured and maintained availability of records during the emergency. Findings: Review of the HHA’s emergency preparedness plan and emergency preparedness binder was conducted on 11/12/24, and showed the agency’s P&P did not address a system of medical documentation that secured and maintained the availability of the records. On 11/14/24 at 1420 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on document review and interview, the agency failed to ensure the HHA’s emergency preparedness P&P included the use of the volunteers in an emergency including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This failure created the risk of not effectively utilizing the available personnel during the emergency events. Findings: Review of the HHA’s emergency preparedness plan and emergency preparedness binder was conducted on 11/12/24 and showed the P&P did not include the use of volunteers in an emergency including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On 11/14/24 at 1420 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on document review and interview, the agency failed to develop the emergency communication plan to include the name and contact information of volunteers, creating the risk of not able to contact or request for assistance in the emergency events. Findings: Review of the HHA’s emergency preparedness plan and emergency preparedness binder was conducted on 11/12/24, and showed the communication plan did not include the name and contact information of volunteers. On 11/14/24 at 1420 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on document review and interview, the agency failed to develop the emergency communication plan to include an alternate means of communication with federal agencies, creating the risk of not able to contact or request for assistance in the emergency events. Findings: Review of the HHA’s emergency preparedness plan and emergency preparedness binder was conducted on 11/12/24, showed the communication plan failed to include an alternate means of communication with federal agencies. On 11/14/24 at 1420 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness communication plan included the method for sharing information and medical documentation for the HHA’s patients with other health providers to maintain the continuity of care, creating the increased risk of not providing appropriate, consistent, and quality care to the patients of the HHA during the emergency events. Findings: Review of the HHA’s emergency preparedness plan and emergency preparedness binder was conducted on 11/12/24, showed the communication plan failed to include the method for sharing information and medical documentation for the HHA’s patients with other health providers to maintain the continuity of care. On 11/14/24 at 1420 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on document review and interview, the agency failed to include the emergency exercises included the analysis of the emergency response and revise the emergency plan as needed, creating the risk of not knowing the priorities in the case of emergency. Findings: Review of the HHA’s emergency preparedness plan and emergency preparedness binder was conducted on 11/12/24, showed the emergency exercises failed to include the analysis of the emergency response and revise the emergency plan as needed. On 11/14/24 at 1420 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the hospice failed to document the reasons for conducting or selecting the PI projects for the 2022, 2023, and 2024 and consistently measure the progress achieved on these projects. This created the risk of not identifying the opportunity for improvement for care and services provided to the HHA’s patients. Findings: The HHA’s P&P titled Performance Improvement Plan revised dated 10/2003 showed the agency shall maintain a performance improvement program that will be implemented by a performance improvement committee. The program shall be ongoing focused on patient outcomes that are measurable and have a written plan of implementation. The performance improvement committee included the following functions: review all activities on a quarterly basis; review all changes in policies and procedures; review all regulatory reports; and review all incident reports, complaints, and grievances. The committee shall meet at least four times a year to identify: the types of services; types of patients served; personnel; governance issues; clinical activities; support services and processes, rights, responsibilities, and ethics; assessment; care, treatment, and service; education; leadership; management of information; management of human resources; management of the environment; and surveillance, prevention, and control of infection. The committee shall consist of a physician, administrator or designee, supervising nurses/therapist, clinician, and medical records. Review of the QAPI meeting minutes from the 2nd, 3rd, and 4th quarters of 2022; the 1st, 2nd, 3rd, and 4th quarters of 2023; and the 1st, 2nd, and 3rd quarters of 2024 was conducted on 11/13/24. Documentation showed the reevaluation of the PIP project was to monitor patient hospitalization of the past quarter. Documentation showed the number of patient hospitalization, number of patient admitted to the hospital within the last 30 days of SOC, and the reason for patient hospitalization. The following were identified: 1. The QAPI meeting minutes showed from the 2nd quarter of 2022 to the 3rd quarter of 2024, showed the HHA had the same PIP project. * However, there was no documentation of the reason why the HHA decided to conduct the PIP. 2. There was no documented evidence a physician attended the quarterly QAPI/PIP meeting as per the agency’s P&P. 3. The QAPI meeting minutes showed the PIP data was not consistent on what was discussed during the QAPI meeting. In addition, the information in the QAPI meeting minutes on what increased or decreased for the past quarter was not specified. For example: a. The 1st quarter of 2023 QAPI meeting minutes dated 4/21/23, showed the following: - The HHA continue to monitor patient hospitalization for the past quarter. -The average hospitalization for the 1st quarter was 57% of which 17% was re-hospitalized within the first 30 days. -A very significant increase was noted for the past quarter with 13 identified reasons for hospitalization. No diagnosis was consistent in the findings. The 1st quarter of 2023 reasons for re-hospitalization graph and the patient list showed there were 10 reasons for hospitalization. * However, the QAPI meeting minutes, re-hospitalization graph, and patient list were not consistent as to the number of reasons for hospitalization. * In addition, the increase noted for the past quarter pertaining to the QAPI meeting minute documents did not specify if the increase was about patient hospitalization or patient admitted to the hospital within the last 30 days of SOC. b. The 3rd quarter of 2024 QAPI meeting minutes dated 10/18/24, showed there were a total of 34 patients hospitalized. Th3 3rd quarter of 2024 patient listing showed there were 20 patients hospitalized. * However, the number of patients hospitalized was not consistent on both documents. 3. The QAPI meeting minutes from the 2nd quarter of 2022 to the 3rd quarter of 2024, showed the reevaluation of the PIP was conducted. Documentation showed the HHA continued to monitor patient hospitalization for the past quarter. Documentation from the 2nd quarter of 2022 to the 3rd quarter of 2024, showed the same recommendations by the QAPI committee whether there was an increase or decrease identified for the past quarter when the PIP was reevaluated. On 11/13/24 at 0944 hours, an interview was conducted with the DPCS. She stated the PIP project was patient hospitalization. She stated the QAPI committee meets quarterly. She stated the 1st quarter was from January to March; 2nd quarter was from April to June; 3rd quarter was from July to September; and 4th quarter was from October to December. Documentation showed the QAPI meeting are held a few days after the quarter. The DPCS stated the QAPI committee included the DPCS, Administrator, other discipline such as PT/OT. DPCS stated the QAPI meeting was not attended by a physician/medical director. On 11/14/24 at 1000 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings.”

“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 agency failed to ensure to maintain an infection control program related to the recapping of needles for one of seven sampled patients (Patient 6), creating the risk of the spread of infections. Findings: According to OSHA Fact Sheet titled Protecting Yourself When Handling Contaminated Sharps dated 01/2011, a needlestick or a cut from a contaminated sharp can result in a worker being infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other bloodborne pathogens. The standard specifies measures to reduce these types of injuries and the risk of infection. Careful handling of contaminated sharps can prevent injury and reduce the risk of infection. Employers must ensure that workers follow these work practices to decrease the workers’ chances of contracting bloodborne diseases. Recapping, bending, or removing needles is permissible only if there is no feasible alternative or if such actions are required for a specific medical or dental procedure. If recapping, bending, or removal is necessary, employers must ensure that workers use either a mechanical device or a one-handed technique. The cap must not be held in one hand while guiding the sharp into it or placing it over the sharp. A one-handed “scoop” technique uses the needle itself to pick up the cap, and then the cap is pushed against a hard surface to ensure a tight fit onto the device. Also, the cap may be held with tongs or forceps and placed over the needle. Sharps disposal containers must be readily accessible and located as close as feasible to the area where sharps will be used. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. A joint home visit with LVN 1 was conducted on 11/7/24 at 1000 hours, to Patient 6’s home. The following was observed: * Patient 1 was sitting on a chair in a common area. LVN 1 administered Basaglar (antidiabetic) SC on the patient’s left lower abdomen. LVN 1 recapped the needle using one hand holding the cap and the other hand holding the injection pen (device used for injecting medication under the skin). * LVN 1 administered Ozempic (antidiabetic) SC on the patient’s right lower abdomen. LVN 1 recapped the needle using one hand holding the cap and the other hand holding the injection pen. * LVN 1 discarded the used needles in a sharp container located in the patient’s room. The sharp container was not readily accessible. LVN 1 had to walk several steps and open the curtain to access the patient’s room where the sharp container was located. On 11/7/24 at 1115 hours, an interview was conducted with LVN 1. She stated the needles that were used to administer Basaglar and Ozempic were not retractable. LVN 1 verified she used two hands to recap the needle. She stated if it was a long needle she would use one hand and push the injection pen on a hard surface to recap the needle. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the above findings.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview, HHA document review, and HHA P&P review, and the agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, and control of infections. This failure had the potential for spread of infections. Findings: The agency’s P&P titled Infection Control Plan dated 10/2009, showed the agency defines and implements an infection control program to reduce the risks for infections in patients, families, caregivers, and staff. The program policies and procedures will address prevention and control activities including, but not limited to: -Surveillance -Systems to track occurrence and transmission of infection -The agency’s process for identification or infection among patient, families, caregivers, and staff a. Defines types of infections in patients and staff must be reported b. Reviews and analyzes infection data, identifying unusual patterns and trends c. Reviewed patient clinical records for identification of infections, reported and unreported, for appropriateness and adequacy of treatment and services. d. Acts on infection findings to decrease the risk of infection. On 11/13/24 at 0944 hours, an interview was conducted with the DPCS on the HHA’s infection control program. She stated the following information: -The DPCS will fill out the individualized infection control report soon as the information was available. -The LVN Care Coordinator will collect data monthly for infection cases and summarize quarterly. -The DPCS will analyze the quarterly data. -Recommendation will be done by the QAPI committee during the QAPI quarterly meeting. Review of the infection control documents from the 2nd, 3rd, and 4th quarters of 2022; 1st, 2nd, 3rd, and 4th quarters of 2023; and the 1st, 2nd, and 3rd quarters of 2024 was conducted on 11/13/24. The following were identified: 1. The quarterly infection control document which contained the list of patients with the respective type of infection and the quarterly QAPI meeting minute data on infection control did not contain consistent data related to the number and types of infection. For example: a. The 4th quarter of 2023 list of patients with the respective type of infection showed the following information: Urinary infection 4 Wound Infection 2 Respiratory Infection 1 Oral 1 The 4th quarter of 2023 QAPI meeting minutes under the Infection Control Report dated 1/19/24, showed the following information: Urinary infection 6 Wound Infection 2 Respiratory Infection 1 Oral 0 * However, the number of urinary infection cases and oral cases were not consistent on both documents. b. The 1st quarter of 2024 list of patients with the respective type of infection showed the following information: Urinary infection 11 Wound Infection 4 Skin Infection 2 Covid-19 infection 1 Other infection 0 The 1st quarter of 2024 QAPI meeting minutes under the Infection Control Report dated 4/19/24, showed the following information: Urinary infection 9 Wound Infection 7 Skin Infection 1 Covid-19 infection 1 Other infection 1 * However, the number of urinary, wound, skin, oral, and other infection cases were not consistent on both documents. 2. The quarterly infection control document which contained the list of patients with the respective type of infection and the quarterly infection control finding was not consistent. For example: The 2nd Quarter of 2023 list of patients with the respective type of infection showed eight patients who had UTI. Six of the eight patients had a urinary catheter. The 2nd Quarter of 2023 infection control finding showed UTI continue to be the primary affected system. Documentation showed “5 of 9 cases” have Foley catheters, either indwelling or intermittent. * However, the data on the 2nd quarterly list of patients who had UTI including the urinary catheters was not consistent with the 2nd quarterly infection control finding. 3. The agency failed to identify the increase in the number of other types of infection and develop an action plan. For example: The 4th quarter of 2023 list of patients with the respective type of infection showed there were six urinary infection cases and two wound infection cases. The 1st quarter of 2024 list of patients with the respective type of infection showed there were 11 urinary infection cases and four wound cases The 1st quarter of 2024 finding showed the UTI continue to be primary affected system. Documentation showed UTI prevention and hygiene will be focus, E. Coli was the most common bacteria; skilled nurse to reinforce patient education of prevention of UTIs; use of “PROVON” wipes for patient with catheters and reoccurring UTI’s; and used closed system for catheter irrigation if possible. * However, the HHA failed to identify the increase in wound infection cases and there was no documented evidence of an action plan. On 11/14/24 at 1000 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the above findings.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the agency’s RN had prepared specific patient care instruction for the CHHA to meet the care needs for one of seven sampled patients (Patient 7), creating the increased risk of not providing necessary care and services to the patient. Findings: 1. Review of Patient 7’s clinical record was initiated on 11/6/24, and showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. a. The POC, for the certification period from 10/2/24 to 11/30/24, cited CHHA visits 1W1 and 2W8 to assist with personal care and bathing. The POC also included an instruction for the SN to check the blood pressure only on the right arm and weight patient weekly. The Home Health Aide Care Plan dated 4/1/24, showed CHHA to check vitals every and weight every visit. However, the Home Health Aide Care Plan completed by RN 1 failed to show which arm the BP needs to be obtained. In addition, the Home Health Aide Care Plan was not consistent for the POC for the certification periods 10/2/24 to 11/30/24 on how often the weight was to be obtained. On 11/14/24 at 0930 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the care plan was revised to reflect the specific instructions of checking the blood pressure on the right side and to weight the patient weekly. The Administrator replied, not documented, it should have been revised. The Administrator was informed and acknowledged the findings. b. The POC, for the certification period from 8/3/24 to 10/1/24 cited CHHA visits 2W8 and 1W1 to assist with personal care and bathing. The POC also included an instruction for the SN to check the blood pressure only on the right arm and weight patient weekly. The Home Health Aide Care Plan dated 4/1/24, showed CHHA to check vitals every and weight every visit. However, the Home Health Aide Care Plan completed by RN 1 failed to show which arm the BP needs to be obtained. In addition, the Home Health Aide Care Plan was not consistent for the POC for the certification periods 10/2/24 to 11/30/24 on how often the weight was to be obtained. On 11/14/24 at 1010 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator replied, not documented and it should have been revised. The Administrator was informed and acknowledged the findings.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical records were complete and accurate for two of seven sampled patients (Patients 4 and 7), creating the risk of substandard care provided to this patient as the clinical information was not complete. 2. Review of Patient 4’s clinical record was initiated on 11/7/24, and showed the SOC was 8/16/24. The patient was certified for home health services during the certification period from 8/16/24 to 10/14/24. Review of the LVN Supervisory and 30 Day Progress Note dated 9/14/24, showed the RN had performed the evaluations. However, the section for the signature and date was left blank. On 11/14/24 at 1020 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked regarding the completion of the LVN Supervisory and 30 Day Progress Note on 9/14/24. DPCS stated it should have been signed and dated. The agency’s P&P titled Clinical Records, Medical Record Retention revised 11/1/11, showed any person who gives client care and who is professionally involved in the management and/or coordination of client services may make an entry into the clinical record. The individual must date (month, day, year) and sign the entry, complete with his or title to authenticate an entry in the clinical record. Review of Patient 7’s clinical record was initiated on 11/6/24, and showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. The POC for the certification from 8/3/24 to 10/1/24 cited CHHA visit 2W8, 1W1 to assist with personal care and bathing. Review of the CHHA Supervisory notes dated 9/22/24, showed the RN had performed the supervisory visit. However, the section for the electronic staff signature and date was left blank. On 11/14/24 at 1126 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked as to the the timeline for the staff to sign the visit note. The Administrator replied, should be electronically signed on that day. The Administrator was informed and acknowledged the finding.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessment was completed in a timely manner, consistent with the patient’s immediate needs for one of seven sampled patients (Patient 6). This failure created the risk of not identifying and addressing the care needs timely for this patient. Findings: Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The start of care assessment undated, showed the start of care was 4/2/23. Documentation showed the referral date was 3/31/23. There was no documented evidence of the patient’s assessment of the home bound status, emergency preparedness (acuity level and triage), vital signs, psychosocial, and bowel sounds. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed of the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and clinical record review, the agency failed to ensure the review of the medications included all of the patient’s current medications to identify any potential adverse effects and drug reactions for three of seven sampled patients (Patients 5, 6, and 7). This posed the risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. 3. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24 Review of the medication profile for the certification period from 9/23/24 to 11/21/24, showed the patient’s medication included lactulose (laxative) 10 g/15 ml 30 ml PO QD, Geri-Lanta (antacid) 200-200-20 mg/5ml 30 ml PO QD PRN, and QVAR (steroid) 40 mcg/puff one to two puffs inhalant BID, A joint home visit with LVN 1 was conducted on 11/7/24 at 1000 hours, to Patient 6’s home. Review of the patient’s medications with LVN 1 showed the following information: - The patient did not have the lactulose on stock. LVN 1 stated the patient no longer uses Lactulose. - Qvar had an expiration date of 10/2024. - Geri-lanta had an expiration dated 6/2024. * However, the SN failed to update the medication profile. In addition, the SN failed to ensure the medications were not expired. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. The agency’s P&P titled Medication Assessment revised 3/3/22, showed the SN or Skilled therapist will notify the Case Manager of any discrepancy observed: new medication, dose change in any medication, missing medication, expired medication, medication not in the patient’s medication list with the agency and the Case manager will also update the medication profile and instruct the follow-up SN or Therapist to print out the updated medication list and place in the patient’s folder at home. 1. Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The Medication Profile for the certification period from 9/30/24 to 11/28/24, showed the patient’s medications included clonazepam (benzodiazepine) 1 mg one tablet PO BID, levothyroxine sodium (hormones) 50 mcg one tablet PO QD, Vitamin D3 (supplement) 50 mcg one capsule QD, losartan potassium- hydrochlorothiazide (angiotensin 2 receptor blocker for hypertension) 50-12.5 mg one tablet PO BID, Eliquiz ( factors XA inhibitors-blood thinners) 5 mg one tablet PO BID, Systane lubricant eye drop (artificial tears) one to two drops each eye PRN and Saccharomyces Boulardii (probiotics) 250 mg one capsule PO BID for seven days which was discontinued on 10/21/24. A joint home visit with the PT was conducted on 11/7/24 at 1430 hours, to Patient 5’s home. Review of the patient’s medication with PT, the patient and PCG showed the patient was on Saccharomyces Boulardii 250 mg one capsule PO BID. The patient was asked if he was still taking the medication. The patient replied, only takes it for stomach upset and not taking it regularly. However, the Saccharomyces Boulardi was already discontinued. In addition, review of the home medication includes saline nasal spray 0.65%. The patient was asked as to the last time, he used the medication. the patient replied, once this year. However, the medication was expired as the expiration date showed 1/2002. Further review of the home medication showed the patient has triple antibiotic ointment. The PCG stated, the medication was used for the patient rash on his side. It was used last Friday- 11/1/24. However, the triple antibiotic ointment was not listed on the medication profile. On 11/7/24 at 1535 hours, an interview and medication profile review was conducted with the PT. The PT was asked if the medication list were updated. The PT replied “I don’t check the medication, its for nursing”. On 11/14/24 at 1111 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of Patient 7’s clinical record was initiated on 11/6/24, and showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. The Medication Profile for the certification period from 10/2/24 to 11/30/24, showed the patient’s medications included Fungi Nail Toe and Foot (antifungal) apply as directed BID, amlodipine besylate (antihypertensive) 2.5 mg one tablet at night PRN if BP more than 140, amlodipine 5 mg one tablet PO QD in AM, Refresh 1% (artificial tears) one drop each eye BID, Vitamin C (supplement) 500 mg one tablet BID, Omega 3 (supplement) 1000 mg two soft gels QD, Co Q 10 (alternative medicine) 100 mg one soft gel QD, Cranberry (alternative medicine) 400 mg one tablet PO QD, levothyroxine sodium (thyroid hormone) 50 mcg one tablet PO QD, Ergocalciferol (supplement) 50,000 IU one capsule weekly, furosemide (loop diuretics) 40 mg one tablet every other day alternating with furosemide 20 mg (may take 40 mg dose instead of 20 mg if edema and/or weight gain is noticed), furosemide 20 mg one tablet every other day alternating with furosemide 20 mg, rosuvastatin (antilipidemic) one tablet PO QHS and Bacitracin ointment (topical antibiotic) apply to suprapubic catheter site as directed. A joint home visit with the RN 1 was conducted on 11/8/24 at 0930 hours, to Patient 7’s home. Review of the patient’s medication with RN 1 and PCG, showed the patient was taking the following medications: -Ergocalciferol 50,000 IU one capsule QD instead of weekly. The PCG was asked as to the last time he took the medication. The PCG replied “once a day yesterday” (11/7/24) and -rosuvastatin 5 mg one tablet every Monday, Wednesday and Friday instead of one tablet QHS. The PCG was asked as to the last time the patient took rosuvastatin. The PCG replied, he’s taking it at night time during Mondays, Wednesday and Thursdays. The PCG was also asked as to the timeline when the physician change the frequency for rosuvastatin. The PCG replied, “ I didn’t check with my daughter, probably last month, it’s been awhile”. However, the medication profile was not updated to reflect the changes in the frequency of the above medications. A follow -up interview was conducted with the RN 1. The RN 1 was asked if the medication profile was updated to reflect the changes for Ergocalciferol 50,000 IU and rosuvastatin 5 mg. The RN 1 replied no, should have checked the list on the last time I visited the patient”. The RN 1 was informed and acknowledged the findings. On 11/14/24 at 1001 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for six of seven sampled patients (Patients 2, 3, 4, 5, 6, and 7). This failure had the potential for not addressing the care needs for these patients. 5. Review of Patient 2’s closed clinical record was initiated on 11/6/24, and showed the SOC was 11/22/23. The patient was certified for home health services during the certification period from 1/21/24 to 3/20/24. The patient was discharged from the agency on 3/19/24. a. Review of the Recertification Report dated 1/16/24, showed the RN had performed the body system assessment. However, the section for the height and weight was left blank. b. Review of the SCIC Report dated 2/16/24, showed the RN had performed the body system assessment. However, the section for the height was left blank. On 11/14/24 at 1337 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS verified and acknowledged the findings. 6. Review of Patient 4’s clinical record was initiated on 11/7/24, and showed the SOC was 8/16/24. The patient was certified for home health services during the certification period from 8/16/24 to 10/14/24. Review of the Recertification Report dated 10/10/24, showed the RN had performed the body system assessment. However, the section for the weight was left blank. On 11/14/24 at 1343 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS verified and acknowledged the findings. 3. Review of Patient 3’s clinical record showed the SOC was 9/9/21. The clinical record showed the patient received home health services during the certification periods from 8/24/24 to 10/22/24 and 10/23/24 to 12/21/24. The recertification assessment dated 8/19/24, showed the patient’s information for the pneumonia immunization status and the patient’s height were not completed. On 11/14/24 at 0945 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. 4. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The recertification assessments dated 7/21 and 9/22/24, showed the patient’s information for the pneumonia immunization status and the patient’s height was not completed. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. 1. Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. a. The OASIS E Recertification assessment dated 7/31/24, showed the RN had performed the vital signs assessment to include the patients weight. The assessment also includes functional status, functional abilities and goals, health conditions and skin conditions. Review of the additional documents titled Recertification Report dated 7/31/24, showed the RN had performed the body system assessment. However, the assessment for the section of height was left blank. b. The OASIS E Other Follow up dated 9/21/24, showed the RN had performed an assessment. The assessment includes functional status, functional abilities and goals, health conditions and skin conditions. Review of the additional documents titled SCIC Report dated 9/21/24, showed the RN had performed the body system assessment, vital signs and weight. However, the assessment for the section of height was left blank. On 11/14/24 at 1036 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. c. The OASIS E Recertification dated 9/26/24, showed the RN had performed the vital signs assessment to include the patients weight. The assessment also includes functional status, functional abilities and goals, health conditions and skin conditions. Review of the additional document titled Recertification Report dated 9/26/24, showed the RN had performed the body system assessment and vital signs. However, the section for height and weight was left blank. On 11/14/24 at 1059 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. On 11/14/24 at 1302 hours, a follow up interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 7’s clinical record was initiated on 11/6/24, and showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. a. The OASIS E Recertification assessment dated 9/30/24, showed the RN had performed the vital signs assessment to include the patients weight. The assessment also includes functional status, functional abilities and goals, health conditions and skin conditions. Review of the additional document titled Recertification Report dated 9/30/24, showed the RN had performed the body system assessment and vital signs. However, the section for height and weight was left blank. On 11/14/24 at 0930 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. On 11/14/24 at 1302 hours, a follow up interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. b. The OASIS E Recertification assessment dated 7/29/24, showed the RN had performed the vital signs assessment to include the patients weight. The assessment also includes functional status, functional abilities and goals, health conditions and skin conditions. Review of the additional document titled Recertification Report dated 7/29/24, showed the RN had performed the body system assessment, vital signs and weight. However, the section for height was left blank. On 11/14/24 at 1010 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. On 11/14/24 at 1302 hours, a follow up interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the updated comprehensive assessment was completed within 48 hours of the patient’s return to home from the acute care hospital for one of seven sampled patients (Patients 5). This failure created the risk of not providing the necessary care and services timely to meet the care needs for this patient. Findings: Review of Patient 5’s clinical record was initiated on 11/8/24. The patient’s clinical record showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The OASIS E Transfer Not Discharge dated 10/11/24, showed the patient was transferred to acute care hospital. The OASIS E Resumption of Care dated 10/15/24, under the section of primary reason for home health/medical necessity showed the patient was discharged from an acute hospital on 10/12/24. The assessment includes the assessment of all body system, vital signs, and weight. However, review of the additional document titled ROC Report dated 10/15/24, showed the section for the patient’s height was left blank. Moreover, review of the OASIS E Resumption of Care dated 10/15/24 on the section of Weight loss/Gain, showed the assessment was left blank. On 11/14/24 at 1059 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. On 11/14/24 at 1302 hours, a follow up interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge comprehensive assessments were updated for two of seven sampled patients (Patients 1 and 2). This failure had the potential for not addressing the care needs for this patient. Review of Patient 1’s closed clinical record was initiated on 11/8/24, and showed the SOC was 1/26/24. The patient was certified for home health services during the certification periods from 1/26/24 to 3/25/24 and 3/26/24 to 5/24/24. The patient was discharged from the agency on 5/23/24. The OASIS E Discharge Assessment dated 5/23/24, showed the RN had performed the body system assessment. The assessment included hearing, speech, vision, cognitive patterns, mood, behavior, functional status, functional abilities and goals, bladder and bowel, health conditions. swallowing/nutritional status and skin conditions. However, the assessment failed to show documented evidenced of the cardio respiratory system was assessed. In addition, the assessment failed to include the patients vital signs, height and weight was documented as part of the completed discharge assessment. On 11/14/24 at 0902 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 11/6/24, and showed the SOC was 11/22/23. The patient was certified for home health services during the certification periods from 11/22/23 to 1/20/24 and 1/21/24 to 3/20/24. The patient was discharged from the agency on 3/19/24. Review of the OASIS Discharge Assessment dated 3/19/24, showed the RN had performed the body system assessment. However, the assessment failed to show documented evidence the cardiovascular system was assessed. In addition, the assessment failed to include the documentation of patient’s vital signs, height, and weight as part of the completed discharge assessment. On 11/14/24 at 1337 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was made aware acknowledged the findings. Findings: Review of Patient 1’s closed clinical record was initiated on 11/8/24. The clinical record showed the SOC was 1/26/24. The patient was certified for home health services during the certification periods from 1/26/24 to 3/25/24 and 3/26/24 to 5/24/24. The patient was discharged from the agency on 5/23/24. The OASIS E Discharge Assessment dated 5/23/24, showed the RN had performed the body system assessment. The assessment included hearing, speech, vision, cognitive patterns, mood, behavior, functional status, functional abilities and goals, bladder and bowel, health conditions. swallowing/nutritional status and skin conditions. However, the assessment failed to show documented evidenced of the cardio-respiratory system was assessed. In addition, the assessment failed to include the patients’ vital signs, height and weight was documented as part of the completed discharge assessment. On 11/14/24 at 0902 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 11/6/24. The clinical record showed the SOC was 11/22/23. The patient was certified for home health services during the certification periods from 11/22/23 to 1/20/24 and 1/21/24 to 3/20/24. The patient was discharged from the agency on 3/19/24. Review of the OASIS Discharge Assessment dated 3/19/24, showed the RN had performed the body system assessment. However, the assessment failed to show documented evidence the cardiovascular system was assessed. In addition, the assessment failed to include the documentation of patient’s vital signs, height, and weight as part of the completed discharge assessment. On 11/14/24 at 1337 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was made aware acknowledged the findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to revise and update the POC for one of seven sampled patients (Patient 6). This failure created the risk for not providing the necessary care and services to this patient. Findings: Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The recertification physician’s order dated 7/21 and 9/22/24, showed under remarks the patient needs daily SN visit for blood sugar monitoring and administration of daily Basaglar (antidiabetic) and weekly Ozempic (antidiabetic) until further notice/orders. The documentation showed the SN assisted the patient to take morning medications daily and filled the “EVENING BOX” for patient to take in the evening. The POC, for the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24, under orders for discipline and treatment showed SN visit daily for Basaglar injection. Medications included loperamide (antidiarrhea) 2 mg one tablet PO Q four hours PRN, clomipramine hcl (antidepressant) 50 mg one capsule PO Q HS, docusate sodium (laxative) 250 mg one capsule PO BID, Q-Tussin DM (cough suppressant/expectorant) 100-10 mg/5 ml one teaspoon PO Q six hours PRN for cough, lorazepam (antianxiety) 0.5 mg one tablet PO BID PRN, ibuprofen (nonsteroidal anti-inflammatory agent) 200 mg one tablet PO Q six hours PRN , Geri-Lanta (antacid) 200-200-20 mg/5ml 30 ml PO QD PRN , Bismatrol (antidiarrhea) 262 mg/15 ml 20 ml PO Q six hours PRN, acetaminophen (analgesic) 325 mg one tablet PO Q eight hours PRN for pain/fever, vitamin D (supplement) 50 mcg one tablet PO QD, rosuvastatin calcium (lipid lowering agent) 20 mg one tablet PO QHS, Omega-3 acid ethyl esters (supplement) 1 g one capsule PO BID, olanzapine (antipsychotic) 20 mg one tablet PO Q evening, olanzapine 10 mg one tablet PO Q morning, metoclopramide hcl (antiemetic) 10 mg one and a half tablet PO BID, lisinopril (antihypertensive) 40 mg one tablet PO QD, lactulose (laxative) 10 gm/15 ml 30 ml PO QD, Thera tab (supplement) one tablet PO QD, Dexilant (used to treat heartburn) 30 mg one capsule PO QD before breakfast, Basaglar 100 u/ml 25 u SC Q morning, Donepezil (cognition enhancing medication) 10 mg PO QHS, Farxiga (antidiabetic) 5 mg one tablet PO QD, Ozempic 0.68 mg/ml 0.25 mg SC weekly x four weeks, Norvasc (antihypertensive) 5 mg one tablet PO QD, memantine (cognition enhancing medication) 10 mg one tablet PO BID, Qvar (steroid) 40 mcg/puff one to two puff inhalant BID, Albuterol sulfate (bronchodilator) 90 mcg/puff two puff inhalant Q six hours PRN for SOB, and pregabalin (anticonvulsant) 300 mg one capsule PO BID. A joint home visit with LVN 1 was conducted on 11/7/24 at 1000 hours, to Patient 6’s home. The LVN checked patient’s blood sugar, administered Basaglar, Ozempic, and morning oral medications. LVN 1 prepared patient’s evening medication and placed in in a pill box. LVN 1 stated LVN would check the blood sugar before administering Basaglar. She stated she would hold the Basaglar if the blood sugar was less than 100 mg/dl. LVN 1 stated the SN assisted in administering morning oral medication and prepared the evening medications in a pill box. * However, the POC for the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24, was not revised to include the SN performing the following: checking of the patient’s blood sugar, assisting with the oral medications, and filling the” EVENING BOX” with the evening medications, and to hold Basaglar 25 u SC in the morning if blood sugar was below 100 mg/dl. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure for an effective communication with the physician for three of seven sampled patients (Patients 3, 4, and 7), creating the risk of not providing necessary care and services to these patients. 3. Review of Patient 7’s clinical record was initiated on 11/6/24, and showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. a. The POC, for the certification period from 10/2/24 to 11/30/24, cited SN 1W1,2W8 for skilled observation of vital signs and body system assessment. The POC included for the SN to weight the patient weekly. Review of the SN notes dated 10/3, 10/7, 10/11, 10/14,10/17,10/21, 10/24,10/28 and 10/30/24, showed the SN weight the patient every visit. However, the order was to weight the patient weekly. On 11/7/24 at 0930 hours, a joint home visit was conducted with RN 1 to Patient 7’s home. The RN 1 was asked as to the frequency of weighing the patient. The RN 1 replied every visit but the order was weekly. The RN 1 was also asked if the physician was notified or coordinated about the changes in the frequency of patients weight. The RN 1 replied, no, should have been notified. The RN 1 was informed of the findings. b. The POC, for the certification period from 8/3/24 to 10/1/24, cited SN 2W8,1W1 for skilled observation of vital signs and body system assessment. The POC included for the SN to weight the patient weekly. Review of the SN notes dated 8/5, 8/8, 8/12, 8/15, 8/19, 8/23, 8/26, 8/29, 9/3, 9/6, 9/9, 9/12, 9/16, 9/23 and 9/26/24, showed the SN checked the patients weight every visit instead of weekly as ordered in the POC. However, review of the clinical record failed to show documented evidenced of the physician was notified of the changes in frequency of checking the patients weight. On 11/14/24at 0936 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of Patient 4’s clinical record was initiated on 11/7/24, and showed the SOC was 8/16/24. The patient was certified for home health services during the certification period from 10/15/24 to 12/13/24. Review of the Recertification Report dated 10/10/24, showed the RN performed the body system assessment. The assessment showed patient had 7/10 pain level on both shoulder. Review of the SN Visit Notes, showed patient had 5/10 pain level on 10/23/24, 6/10 pain level on 10/31/24, and 5/10 pain level on 11/5/24. Further review of clinical record failed to show documented evidence the PCP was notified of patient’s pain. On 11/14/24 at 1343 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS verified there were no PCP notification of patient’s pain. The DPCS acknowledge the PCP should have been notified. Findings: 1. Review of Patient 3’s clinical record showed the SOC was 9/9/21. The clinical record showed the patient received home health services during the certification periods from 8/24/24 to 10/22/24 and 10/23/24 to 12/21/24. The clinical record showed the patient was seen by a wound care company once a week. The wound care company’s progress notes dated 8/27, 9/3, 9/10, 9/17, 9/24, 10/1, 10/8, 10/15, 10/22, 10/29, and 11/6/24, showed dietary recommendations for wound healing included vitamin A (supplement), vitamin C (supplement), and zinc (supplement). Documentation showed refer to PCP for recommendations. * However, there was no documented evidence the dietary recommendations were coordinated with the patient’s PCP. On 11/14/24 at 0945 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the necessary care and services were coordinated for one of seven sampled patient (Patient 4). This failure had the potential for not providing the necessary care and services to this patient. Review of Patient 4’s clinical record was initiated on 11/7/24, and showed the SOC was 8/16/24. The patient was certified for home health services during the certification period from 8/16/24 to 10/14/24. a. Review of the Telehealth Hospital Discharge Follow-up Progress Note dated 8/17/24, showed the patient was assessed and the plan included a urology referral. Review of the Urinalysis Culture Result collected on 8/23/24, showed the physician was notified and responded to the results on 8/26/24. The document further showed the physician ordered a urology follow-up. On 11/14/24 at 1020 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS verified the patient needed a urology follow-up. When asked if the urology follow up was coordinated, the DPCS stated it was not. b. Review of the PT Initial Evaluation dated 8/21/24, showed the patient had 5/10 pain level and the aggravating factors were movement and ambulation. Review of the PT Therapy Progress Notes, showed the patient had 5/10 pain level on 8/26/24, 4/10 pain level on 8/29/24, 4/10 pain level on 9/2/24, and 3/10 pain level on 9/14/24. Further review of the PT Initial Evaluation and Therapy Progress Notes failed to show documented evidence PT staff notified the RN of patient’s pain. On 11/14/24 at 1020 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS verified there were no notification to the RN regarding patient’s pain level.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the visit schedule for two of seven sampled patients (Patients 5 and 6). This failure had the potential for not providing the necessary information to these patients. 2. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The POC, for the certification period from 9/23/24 to 11/21/24, showed SN visits daily for 60 days. On 11/7/24 at 1000 hours s, a joint home visit was conducted with LVN 1 to Patient 6’s home. Review of the patient’s admission packet provided by the HHA showed no documented evidence of written instructions outlining the SN visit schedules. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. 1.Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The POC, for the certification period from 9/29/24 and 9/30/24 to 11/28/24, cited PT 2W1,1W4 for evaluation and treatment. The Physicians order dated 10/2/24, showed a decrease on PT visit to one time a week on Week 1. Continue PT visits 1w1,2w1,1w3 effective 10/3/24. The order also showed, PT visits only. Review of the Physicians order dated 10/14/24 at 0255 hours, showed an order for an RN visit to perform all body systems assessment and to resume home health services. Review of the Physicians order dated 10/15/24, showed an order for a resumption of care. The order cited SN visits 2W2, 1W5. A joint home visit with the PT was conducted on 11/7/24 at 1430 hours, to Patient 5’s home. The patient/PCG was asked for the written instructions outlining the SN and PT visits. The PCG replied they called today to schedule a visit, “maybe there was another visit calendar with his son, but its not here”. Review of the patients home handbook provided by the HHA, showed the visit calendar was left blank and there was no documented evidenced of the written instructions outlining the SN and PT visits. The PT was also asked if she use a visit calendar. The PT replied, we have PTA, I only do evaluations, the visit calendar was not filled up”. On 11/14/24 at 1111 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. Findings: 1. Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The POC, for the certification period from 9/29/24 and 9/30/24 to 11/28/24, cited PT 2W1 (two visits a week for one week), and 1W4 for evaluation and treatment. The physician’s order dated 10/2/24, showed a decrease on PT visit to one time a week on Week 1. Continue PT visits 1w1,2w1,1w3 effective 10/3/24. The order also showed, PT visits only. Review of the physician’s order dated 10/14/24 at 0255 hours, showed an order for an RN visit to perform all body systems assessment and to resume home health services. Review of the Physicians order dated 10/15/24, showed an order for a resumption of care. The order cited SN visits 2W2, 1W5. A joint home visit with the PT was conducted on 11/7/24 at 1430 hours, to Patient 5’s home. The patient/PCG was asked for the written instructions outlining the SN and PT visits. The PCG replied they called today to schedule a visit, “maybe there was another visit calendar with his son, but it’s not here.” Review of the patient’s home handbook provided by the HHA, showed the visit calendar was left blank and there was no documented evidenced of the written instructions outlining the SN and PT visits. The PT was also asked if she use a visit calendar. The PT replied, we have PTA, I only do evaluations, the visit calendar was not filled up.” On 11/14/24 at 1111 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The POC, for the certification period from 9/23/24 to 11/21/24, showed SN visits daily for 60 days. On 11/7/24 at 1000 hours, a joint home visit was conducted with LVN 1 to Patient 6’s home. Review of the patient’s admission packet provided by the HHA showed no documented evidence of written instructions outlining the SN visit schedules. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the patient medication schedule/instructions, including medication name, dosage, and frequency and which medications would be administered by the HHA personnel and the patient/PCG for one of seven sampled patient (Patient 6), creating the risk of not providing the necessary information to this patient. Findings: Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The POC, for the certification periods from 9/23/24 to 11/21/24, under orders for discipline and treatment showed SN visit daily for Basaglar injection. Medications included loperamide (antidiarrhea) 2 mg one tablet PO Q four hours PRN, clomipramine hcl (antidepressant) 50 mg one capsule PO Q HS, docusate sodium (laxative) 250 mg one capsule PO BID, Q-Tussin DM (cough suppressant/expectorant) 100-10 mg/5 ml one teaspoon PO Q six hours PRN for cough, lorazepam (antianxiety) 0.5 mg one tablet PO BID PRN, ibuprofen (nonsteroidal anti-inflammatory agent) 200 mg one tablet PO Q six hours PRN , Geri-Lanta (antacid) 200-200-20 mg/5ml 30 ml PO QD PRN , Bismatrol (antidiarrhea) 262 mg/15 ml 20 ml PO Q six hours PRN, acetaminophen (analgesic) 325 mg one tablet PO Q eight hours PRN for pain/fever, vitamin D (supplement) 50 mcg one tablet PO QD, rosuvastatin calcium (lipid lowering agent) 20 mg one tablet PO QHS, Omega-3 acid ethyl esters (supplement) 1 g one capsule PO BID, olanzapine (antipsychotic) 20 mg one tablet PO Q evening, olanzapine 10 mg one tablet PO Q morning, metoclopramide hcl (antiemetic) 10 mg one and a half tablet PO BID, lisinopril (antihypertensive) 40 mg one tablet PO QD, lactulose (laxative) 10 gm/15 ml 30 ml PO QD, Thera tab (supplement) one tablet PO QD, Dexilant (used to treat heartburn) 30 mg one capsule PO QD before breakfast, Basaglar 100 u/ml 25 u SC Q morning, Donepezil (cognition enhancing medication) 10 mg PO QHS, Farxiga (antidiabetic) 5 mg one tablet PO QD, Ozempic 0.68 mg/ml 0.25 mg SC weekly x four weeks, Norvasc (antihypertensive) 5 mg one tablet PO QD, memantine (cognition enhancing medication) 10 mg one tablet PO BID, Qvar (steroid) 40 mcg/puff one to two puff inhalant BID, Albuterol sulfate (bronchodilator) 90 mcg/puff two puff inhalant Q six hours PRN for SOB, and pregabalin (anticonvulsant) 300 mg one capsule PO BID. A joint home visit with LVN 1 was conducted on 11/7/24 at 1000 hours, to Patient 6’s home. * However, review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the patient’s medication schedule/instructions, including medication name, dosage, and frequency and which medications would be administered by the HHA personnel and of the patient/PCG. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the above findings.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the contact information of the clinical manager for two of seven sampled patients (Patients 5 and 6). This failure had the potential for not providing the necessary information to these patients. 2. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. On 11/7/24 at 1000 hours, a joint home visit was conducted with LVN 1 to Patient 6’s home. Review of the patient’s admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA’s clinical manager. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. 1.Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The POC, for the certification period from 9/29/24 and 9/30/24 to 11/28/24, cited PT 2W1,1W4 for evaluation and treatment. The Physicians order dated 10/2/24, showed a decrease on PT visit to one time a week on Week 1. Continue PT visits 1w1,2w1,1w3 effective 10/3/24. The order also showed, PT visits only. Review of the Physicians order dated 10/14/24 at 0255 hours, showed an order for an RN visit to perform all body systems assessment and to resume home health services. Review of the Physicians order dated 10/15/24, showed an order for a resumption of care. The order cited SN visits 2W2, 1W5. A joint home visit with the PT was conducted on 11/7/24 at 1430 hours, to Patient 5’s home. The patient/PCG was asked for the contact information of the agency’s clinical manager. The PCG replied “ maybe it’s with his son”. Review of the patients home handbook provided by the agency failed to show documented evidenced of the agency’s clinical manager contact information. The PT was asked if the contact information of the agency’s clinical manager was written on the handbook. The PT replied, no. On 11/14/24 at 1111 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. Findings: 1.Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The POC, for the certification period from 9/29/24 and 9/30/24 to 11/28/24, cited PT 2W1,1W4 for evaluation and treatment. The physician’s order dated 10/2/24, showed a decrease on PT visit to one time a week on Week 1. Continue PT visits 1W1, 2W1, and 1W3 effective 10/3/24. The order also showed, PT visits only. Review of the physician’s order dated 10/14/24 at 0255 hours, showed an order for an RN visit to perform all body systems assessment and to resume home health services. Review of the physician’s order dated 10/15/24, showed an order for a resumption of care. The order cited SN visits 2W2 and 1W5. A joint home visit with the PT was conducted on 11/7/24 at 1430 hours, to Patient 5’s home. The patient/PCG was asked for the contact information of the agency’s clinical manager. The PCG replied “ maybe it’s with his son.” Review of the patient’s home handbook provided by the agency failed to show documented evidenced of the HHA’s clinical manager contact information. The PT was asked if the contact information of the HHA’s clinical manager was written on the handbook. The PT replied, no. On 11/14/24 at 1111 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. On 11/7/24 at 1000 hours, a joint home visit was conducted with LVN 1 to Patient 6’s home. Review of the patient’s admission packet provided by the HHA showed no documented evidence of the name and contact information of the HHA’s clinical manager. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patients received care and services as per the written POCs for six of the seven sampled patients (Patients 1, 2, 3, 5, 6, and 7). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. . 6. Review of Patient 2’s closed clinical record was initiated on 11/6/24, and showed the SOC was 11/22/23. The patient was certified for home health services during the certification period from 1/21/24 to 3/20/24. The patient was discharged from the agency on 3/19/24. The POC, for the certification period from 1/21/24 to 3/20/24, cited SN visits 1WK8 starting the week of 1/28/24. The POC showed SN to assess the respiratory status, pain/symptom control, weight, and s/s for bleeding, monitor patient’s oxygen saturation every SN visit and notify MD if O2 is less than 90%, and weigh patient every week and notify MD if patient gains more than three pounds per week. Review of SN visit note dated 2/29, 3/8, and 3/16/24, showed the SN had performed the body system assessment. However, review of the visit note for 2/29, 3/8, and 3/16/24 failed to show the documentation of patient’s weight, oxygen saturation, pain scale and skin assessment for any bleeding. On 11/14/24 at 1002 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was made aware and acknowledged the above findings. 4. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The POC, for the certification periods from 7/25/24 to 9/22//24, showed SN daily visits for Basaglar (antidiabetic) injection. The POC included to assess for pain/symptom control. The patient’s pain was not assessed as per the POC. For example: The SN notes dated 8/20, 8/21, 8/23, 8/24, 8/26, 8/27, 8/28, 8/29, 8/30, 8/31, 9/3, 9/12, 9/17, and 9/19/24, showed no documented evidence the patient’s pain was assessed. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. 5. Review of Patient 3’s clinical record showed the SOC was 9/9/21. The clinical record showed the patient received home health services during the certification periods from 8/24/24 to 10/22/24 and 10/23/24 to 12/21/24. a. The physician’s orders dated 9/25/24 at 1413 hours, showed the following information: -right lateral lower back and left lateral lower back wounds: Cleanse with NSS, pat dry, apply mupirocin ointment 2% (topical antibiotic) for prophylaxis, then calcium alginate (wound dressing), and cover with bordered gauze dressing. Change dressing every two days and PRN soiled/loss of integrity. * The SN note dated 9/27, 9/29, and 10/3/24, showed the SN performed wound care on the following sites: - left lateral lower back: Cleansed with NSS, patted dry, applied calcium alginate then covered with bordered gauze dressing. However, there was no documented evidence of the application of mupirocin ointment 2%. -right lateral lower back: Cleansed with NSS, patted dry, packed with Iodoform (wound dressing), then covered with bordered gauze dressing, instead of the application of mupirocin ointment 2% for prophylaxis then calcium alginate. b. The physician’s order dated 10/30/24, showed to discontinue the following treatment on the patient’s right upper back: cleanse with NSS, pat dry, apply mupirocin ointment 2% (topical antibiotic) for prophylaxis then calcium alginate, and cover with bordered gauze dressing. Documentation showed to apply skin barrier daily and PRN for skin maintenance on patient’s right upper back. * The SN note dated 10/31, 11/2, 11/4, and 11/8/24, showed the SN performed wound care on the patient’s right upper back by cleansing with NSS, applying mupirocin ointment 2% for prophylaxis, then calcium alginate and covering with bordered gauze dressing, instead of a skin barrier. On 11/14/24 at 0945 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. 1. Review of Patient 1’s closed clinical record was initiated on 11/8/24, and showed the SOC was 1/26/24. The patient was certified for home health services during the certification periods from 1/26/24 to 3/25/24 and 3/26/24 to 5/24/24. The patient was discharged from the agency on 5/23/24. a. The POC, for the certification period from 3/26/24 to 5/24/24, cited SN visits 1W9. The POC showed SN to monitor patient compliance with blood sugar monitoring every visit and call MD if BS less than 70 or more than 300 mg/dl. SN to review patients BS record weekly and notify MD if O2 is less than 90% and SN to weight patient every week and notify MD if patient gains more than 3 lbs. per week. *Review of the SN visit notes showed the SN had performed assessment and monitoring on Weeks, 1, 2, 4, 5, 6, 7 and 8. The documentation showed the patient refused to have her weights taken. However, on Week 3, failed to show documented evidenced of the SN had checked the patients weight as ordered by the physician. In addition, there was no documented evidenced of the patient refused to have her weights taken on Week 3. *Review of the SN visit notes on Week 3 dated 4/11/24 showed the SN had performed endocrine system assessment. However, on the section for monitored by was left blank. On 11/14/24 at 0902 hours an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if the POC was followed as ordered. The Administrator reviewed the SN visit notes replied, no. The Administrator was informed and acknowledged the findings. b. The POC, for the certification period from 3/26/24 to 5/24/24, cited for OT evaluation and follow up treatment as necessary. However, review of the closed clinical record failed to show documented evidenced of the OT evaluations and follow up treatment was performed as ordered in the POC. On 11/14/24 at 0902 hours an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if there was an OT evaluation performed. The Administrator reviewed the clinical record and replied, no, cannot find anything. The Administrator was also asked as to the timeline for the OT to visit the patient. The Administrator replied, within 48 hours from the order. The Administrator was further asked if the POC was followed. The Administrator replied no. The Administrator was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The POC, for the certification period from 8/1/24 to 9/29/24, cited SN 1W9 for skilled assessment of vital signs, response to medications, body system and pain /symptom control. The POC also include to weight every week and notify MD if patient gains more than 3 pounds per week. a. Review of the OASIS E Recertification dated 7/31/24, showed the patient vital signs and weight was assessed. Review of the SN visit notes dated 8/8, 8/15, 8/22, 8/27, 9/5, 9/13 and 9/20 showed the SN had performed vital signs assessment. However, the SN failed to assessed the patient weight weekly as ordered in the POC. b. Review of the SN notes dated 8/1 and 8/15/24, showed the SN had performed pain assessment. The patient was assessed to have pain level of 3 (scale 0 to 10), located at the right rib. The section for “effective?” was marked as checked. In addition, review of the SN notes dated 8/8 and 8/22/24, showed the patient was assessed to have a pain level of 4, located at the lower back. The section for “effective?” was marked as checked. Moreover, review of the SN notes dated 9/5/24, showed the patient was assessed to have a pain level of 3. The section for “effective?” was marked as checked However, there was no documented evidenced of the pain control was provided as per POC. On 11/14/24 at 1036 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the patient weight was checked weekly as per POC. The Administrator replied no documentation. The Administrator was also asked if there was an intervention provided to addressed the pain. The Administrator replied cannot tell, no intervention was documented. The Administrator was informed and acknowledged the findings. 3. Review of Patient 7’s clinical record was initiated on 11/6/24, and showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. a. The POC, for the certification period from 8/3/24 to 10/1/24, cited SN 2W8,1W1 for skilled observation of vital signs and body system assessment. The POC included for the SN to change patient’s drainage bag every 10 days as ordered by the MD. Review of the SN notes dated 8/23, 8/26, 8/29, 9/6, 9/9, 9/12, 9/16, 9/19, 9/23 and 9/26/24 under the section of Analysis/Intervention/Instructions/Patient Response showed the SN had changed the patients urine bag. However, the SN changed the urine drainage bag more frequent than 10 days as ordered by the physician. On 11/14/24at 1010 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if there was a new order for the frequency of changing the urine bag. The Administrator replied, no new order, not following the POC. The Administrator was informed and acknowledged the findings. b. The POC, for the certification period from 10/2/24 to 11/30/24, cited SN 1W1,2W8 for skilled observation of vital signs and body system assessment. The POC included for the SN to change patient’s drainage bag every 10 days as ordered by the MD. Review of the SN notes dated 10/3, 10/7, 10/11, 10/17 and 10/24/24 under the section of Analysis/Intervention/Instructions/Patient Response showed the SN had changed the patients urine bag. However, the SN changed the urine drainage bag more frequent than 10 days as ordered by the physician. On 11/14/24at 0936 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if there was a new order for the frequency of changing the urine bag. The Administrator replied, no new order, not following the POC. The Administrator was informed and acknowledged the findings.”

“Patient, caregiver, and family counseling CFR(s): 484.75(b)(4) Patient, caregiver, and family counseling; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient/PCG teaching on care and services was provided to one of seven sampled patients (Patient 2). This failure posed a risk of not providing the necessary care and services to this patient. Findings: Review of Patient 2’s closed clinical record was initiated on 11/6/24. The clinical record showed the SOC was 11/22/23. The patient was certified for home health services during the certification period from 1/21/24 to 3/20/24. The patient was discharged from the agency on 3/19/24. The POC, for the certification period from 1/21/24 to 3/20/24, cited SN visits 1WK8 starting the week of 1/28/24. The POC showed SN to teach patient/PCG on the pain control measures, s/s (signs and symptoms) of bleeding, inhalation medication, and care of the equipment, oxygen use and care of equipment, and bleeding precaution. Review of SN visit notes dated 2/29, 3/8, and 3/16/24, showed the SN visited and assessed the patient. However, review of the SN visit notes for 2/29, 3/8, and 3/16/24 failed to show the SN educated the patient/PCG on pain control measures, s/s bleeding, inhalation medication and care of equipment, oxygen use and care of equipment, and bleeding precaution. On 11/14/24 at 1002 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was made aware and acknowledged the above findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical records were complete and accurate for four of seven sampled patients (Patients 1, 5, 6, and 7), creating the risk of substandard of care provided to these patients as their clinical information were not accurate and complete. 4. Review of Patient 6’s clinical record showed the SOC was 4/2/23. The clinical record showed the patient received home health services during the certification periods from 7/25/24 to 9/22/24 and 9/23/24 to 11/21/24. The POC, for the certification periods from 7/25/24 to 9/22//24, showed SN daily visits for Basaglar (antidiabetic) injection. The POC included to assess for pain/symptom control. The SN note dated 7/29/24, showed the patient’s pain scale was 3/10 to lower back. Documentation showed “Effective?” was marked. The SN note dated 8/19/24, showed the patient’s pain scale was 3/10 to both lower extremities. Documentation showed “Effective?” was marked. * However, there was no documented evidence on what interventions were provided for SN to mark “effective?” b. Review of the clinical record showed inconsistencies on Patient 6’s RBS. For example: * The SN note dated 9/30/24 showed under the endocrine system assessment the patient’s RBS was 155 mg/dl. The narrative section of the note showed the patient’s RBS during the visit was 103 mg/dl, which was not consistent. * The SN note dated 10/11/24, showed under the endocrine system assessment the patient’s RBS was 147 mg/dl. The narrative section of the note showed the patient’s RBS during the visit was 112 mg/dl, which was not consistent. * The SN note dated 10/12/24, showed under the endocrine system assessment the patient’s RBS was 130 mg/dl. The narrative section of the note showed the patient’s RBS during the visit was 112 mg/dl, which was not consistent. On 11/14/24 at 0914 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed of the findings. 1. Review of Patient 1’s closed clinical record was initiated on 11/8/24, and showed the SOC was 1/26/24. The patient was certified for home health services during the certification periods from 1/26/24 to 3/25/24 and 3/26/24 to 5/24/24. The patient was discharged from the agency on 5/23/24. a. The POC, for the certification period from 3/26/24 to 5/24/24, cited SN visits 1W9. SN to monitor oxygen saturation every visit and notify MD if less than 90%. Review of the SN notes dated 3/26, 4/3, 4/11, 4/18, 4/25, 5/1, 5/8 and 5/15/24 showed the SN had performed respiratory assessment. The assessment showed a check marked on the section of SOB, with exertion/activity and O2 saturation. However, the section for oxygen saturation percentage was left blank. b. Review of the OASIS E Discharge dated 5/23/24 on the section of Discharge Summary, showed the summary of care includes the patient needs skilled observation/assessment of all body system, physical/occupational therapy evaluation and CHHA services. However, review of the closed clinical record failed to show documented evidenced of the occupational therapy was provided to the patient. c. Review of the Physician’s Order dated 5/23/24, showed an order for discharge. The narrative reason for discharge showed the SN visited and reassessed the patients all organ system and vital signs recorded. However, review of the closed clinical record failed to show documented evidenced of the patients vital signs were documented. On 11/14/24 at 0902 an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked as to the oxygen saturation was left blank. The Administrator replied, it was a clerical error, there should have been a value documented. The Administrator was also asked if the OT evaluation was performed during the certification period. The Administrator replied, no, the documentation was inaccurate. The Administrator was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The POC, for the certification period from 8/1/24 to 9/29/24, cited SN 1W9 for skilled assessment of vital signs, response to medications, body system and pain /symptom control and edema. a. Review of the SN notes dated 8/8/24, showed the patient was assessed to have pain level of 4 located at the lower back. Further review of the SN notes dated 8/15/24, showed the patient was assessed to have pain level of 3 located at the right rib. However, review of the SN notes dated 8/8 and 8/15/24 on the section of analysis/interventions/instructions/patient response, showed the SN documented the pain denies pain which was inconsistent. b. Review of the SN notes dated 9/20/24, showed the SN had performed cardiopulmonary assessment. The assessment includes a checked marked on edema. However, the location and description of edema was left blank. On 11/14/24 at 1036 an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked at to the location and description of the patients edema. The Administrator reviewed the clinical record and showed the patient edema was not checked. The printed SN assessment was shared with the Administrator showing the section for edema was checked. The Administrator replied, there was a glitch on our system, cannot argue with the printed documents that was provided. The Administrator was also asked if the pain assessment on the narrative note was accurate. The Administrator replied, no, it was not accurate. The Administrator was informed and acknowledged the findings. 3. Review of Patient 7’s clinical record was initiated on 11/6/24, and showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. * On 11/7/24 at 0936 hours, an electronic review of the CHHA Supervisory notes dated 8/11, 8/25 and 9/22/24, showed the supervisory note was blank. On 11/12/24 at 1129 hours, a copy of the electronic CHHA Supervisory note was requested. The DPCS provided the note which was already completed. The DPCS was informed that the documents were blank prior to the request. The DPCS replied “there was a glitched on our back end office, I saw it earlier, it was blank that’s why I called Finale”. The DPCS was informed and acknowledged the findings. * Review of the CHHA visit notes dated 9/3, 9/9 and 9/12/24, showed the CHHA electronically signed the visit notes. However, the visit notes were left blank. On 11/14/24 at 1010 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked as to the the timeline for the CHHA needed to submit the notes. The Administrator reviewed the notes and showed the notes were completed. The Administrator was informed and showed the copy of the notes that was provided on 11/7/24 was blank. The Administrator stated, “ there was a system issue. They cannot sign the notes unless the assessment were completed. The notes were completed and submitted on the same day”. The Administrator was informed and acknowledged the findings.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the hospice failed to ensure the CHHA had provided HA services in accordance with the POC for one of seven sampled patients (Patient 7), creating the risk of not providing appropriate, consistent, and quality care to this patient. Findings: 1. Review of Patient 7’s clinical record was initiated on 11/6/24. The clinical record showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. a. The POC, for the certification period from 10/2/24 to 11/30/24, cited CHHA visits 1W1 and 2W8 to assist with personal care and bathing. The Home Health Aide Care Plan dated 4/1/24, showed CHHA to check vitals every and weight every visit. Review of CHHA 2’s visit notes dated 10/3,10/11, 10/14, 10/17, 10/21, and 10/24/24, showed CHHA 2 had taken the patients vital signs, performed the personal care and bathing. However, review of CHHA 2 visit notes failed to show documented evidenced of the patient weight was checked as ordered on the care plan. On 11/14/24 at 0930 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if there was a documentation of the patient weight was taken during the CHHA visits. The Administrator replied, none documented. The Administrator was informed and acknowledged the findings. b. The POC, for the certification period from 8/3/24 to 10/1/24, cited CHHA visits 2W8 and 1W1 to assist with personal care and bathing. The Home Health Aide Care Plan dated 4/1/24, showed CHHA to check vitals every and weight every visit. Review of CHHA 2’s visit notes dated 8/5, 8/12, 8/15, 8/19, 8/23, 8/26, 8/29, 9/16, 9/19, 9/23, 9/27, and 9/30/24, showed CHHA 2 had taken the patients vital signs, performed the personal care and bathing. However, review of CHHA 2’s visit notes failed to show documented evidenced of the patient weight was checked as ordered on the care plan. On 11/14/24 at 1010 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN identified the CHHA provided services in accordance with the POC for one of the seven sampled patients (Patient 7), creating the risk of not providing appropriate, consistent, and quality care to this patient. Findings: 1. Review of Patient 7’s clinical record was initiated on 11/6/24. The clinical record showed the SOC was 12/12/20. The patient was certified for home health services during the certification periods from 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24. Review of the clinical record for Patient 7 showed the CHHA did not provide HA services in accordance with the POC for this patient. Cross reference G0798, example #1. The CHHA Supervisory notes dated 10/6 and 10/20/24, for the certification periods from 10/2/24 to 11/30/24, showed RN 1 conducted a supervisory visit and the CHHA 2 followed the written POC. However, RN1 failed to identify CHHA 2 did not provide CHHA services in accordance with the POC. In addition, review of the CHHA Supervisory notes dated 8/11, 8/25, 9/8, and 9/22/24 for the certification periods from 8/3/24 to 10/1/24, showed RN 1 conducted a supervisory visit and CHHA 2 followed the written POC. However, RN 1 failed to identify CHHA 2 did not provide CHHA services in accordance with the POC. On 11/14/24 at 0930 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency staff failed to follow the agency’s P&P related to pain assessment, employee orientation, competencies, performance evaluations and health screening were provided as per P&P. These failures had the potential for not addressing the care needs for the agency’s patients. Findings: 1. The agency’s P&P titled Health Screening revised 10/07/03, showed a written health assessment of each employee who has direct patient contact shall be required as a prerequisite of employment, be performed within six months prior to employment or within 15 days of assuming employment with the agency. A written health assessment report shall verify that the employees is free from health conditions which would interfere with the employees ability to performed assigned duties and provide a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter using the 5 TU (Tuberculin Units) Protein Purified Derivative (PPD) Tuberculin skin test. Hepatitis B vaccine and vaccination series shall be made available to all employees who are at risk for exposure to blood and body fluids. This vaccine must be provided at no cost to the employee and acceptance or refusal of the vaccine must be documented. Information obtained during the health screening shall be documented and maintained in a separate confidential employee health file. *Review of CHHA 1’s personnel file showed CHHA 1 was hired on 6/22/23. However, the TB test was completed on 8/5/22, more than six months prior to employment. In addition, review of CHHA 1’s personnel file, showed a documentation of the Hepatitis B vaccination acceptance dated 6/21/23. However, there was no documented evidenced of the Hepatitis B vaccine was received as per policy. *Review of LVN 1’s personnel file showed LVN 1 was hired on 4/29/22. However, there was no documented evidenced of the physical examination was completed prior to employment. *Review of RN 2’s personnel file showed RN 2 was hired on 9/28/22. However, the physical examination was completed on 2/23/22, more than six months prior to employment. On 11/14/24 at 0830 hours and interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. The agency’s P&P titled Orientation, revised 10/7/03, showed each employee of this agency will participate in an orientation program specific to his/her educational background and experience, job description, and the roles and responsibilities as an employee of this agency. The procedure includes each employee hired by this agency shall complete an orientation program that includes, but is not limited to the following topics: Overview of the agency: -Goals, philosophy, and mission, -Organizational structure, -Patient Rights and Responsibilities, -Code of Conduct, -Complaint/Grievance Procedure, -Accident/Incident Policy -Advance Directives -Ethical Issues in Home Care, -OSHA/Blood Borne Pathogens Training -Biohazardous Materials Management, -Infection Control, -Safety in the Workplace, -Body Mechanics and Transfer Techniques, -Driver Safety, -Fire Safety Procedures in the Office and the Patients’ Home and -Electrical Safety. *Review of the personnel file for RNs 1, 2, 3, LVNs 1 and 2, and CHHA 1 failed to show documented evidence of the orientation program was completed as per P&P. On 11/13/24 at 1316 hours and interview and concurrent document review was conducted with the DPCS. The DPCS was asked if the orientation was provided to the staffs. The DPCS replied, we did the orientation, but no checklist was documented on the file. 3. The agency’s P&P titled Performance Evaluations revised 10/7/03, showed a competency - based performance evaluation will be conducted for all employees annually. Evaluation shall also be an ongoing, informal process between employee and his/her supervisor to ensure continued employee growth and development. Review of RN 1’s personnel file showed RN 1 was hired on 1/13/19 as an LVN. The performance evaluation was provided on 1/28/22 and 1/31/24. However, there was no documented evidenced of the performance evaluation was conducted for the year 2023 as per P&P. In addition, review of RN 1’s personnel file showed RN 1 assumed an RN responsibility on 8/1/24. Review of RN 1’s file showed, a signed Job Description for RN dated on 8/1/24. The Summary of Competency Validation for RN 1 includes a competency for vascular access. However, the Vascular Access competencies was left blank. On 11/13/24 at 0916 hours, an interview and concurrent document review was conducted with the LVN/QA. The LVN/QA was asked as to reason why the vascular access competencies were left blank. The LVN/QA replied, RN 1 forgot to fill it out. The LVN/QA was also asked as to the timeline of the completion of the vascular competency. The LVN/QA replied, on 8/1/24. On 11/14/24 at 0830 hours, a follow up interview and document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 4. The agency’s P&P titled Pain Assessment and Reassessment revised 3/2/22, showed the purpose was to define processes for pain assessment and management. The procedure includes each patient receiving skilled nursing services will have pain assessed on initially and on ongoing basis using established criteria including duration, frequency, character and current pain therapy or treatment. Review of Patient 5’s clinical record was initiated on 11/8/24, and showed the SOC was 4/3/24. The patient was certified for home health services during the certification periods from 4/3/24 to 6/1/24, 6/2/24 to 7/31/24, 8/1/24 to 9/29/24 and 9/30/24 to 11/28/24. The POC, for the certification period from 8/1/24 to 9/29/24, cited SN 1W9 for skilled assessment of vital signs, response to medications, body system and pain /symptom control. crossed ref: G:710 example #2 Review of the SN notes dated 8/1 and 8/15/24, showed the SN had performed pain assessment. The patient was assessed to have pain level of 3 (scale 0 to 10), located at the right rib. The section for “effective?” was marked as checked. In addition, review of the SN notes dated 8/8 and 8/22/24, showed the patient was assessed to have a pain level of 4, located at the lower back. The section for “effective?” was marked as checked. However, the section for medication and character of pain was left blank as per P&P. Moreover, review of the SN notes dated 9/5/24, showed the patient was assessed to have a pain level of 3. The section for “effective?” was marked as checked. However, the pain assessment was incomplete as per P&P. On 11/14/24 at 1036 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”