Delano Home Health Care, Inc.

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to assess the patient’s continuing need for home care services for two of 7 sampled patients (Patient 4 and Patient 5). This deficient practice resulted in the continued certification of the patients for home health services to receive the skilled nursing (SN) services. (Refer to G532) 2. The HHA failed to maintain an accurate, current medication profile for one of 7 sampled patients (Patient 5). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. (Refer to G536) The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure all certified patients for home health services receive the highest quality of patient care.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation for Home Health Aide Services as follows: 1.The Home Health Agency (HHA) failed to ensure and provide documented evidence the Certified Home Health Aides (CHHA) successfully completed the competency testing and training, to carry out assigned patient care tasks, in a safe, effective, and efficient manner for five of 7 sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, and Patient 6). This deficient practice placed the patients at risk for bodily injuries related to mishandling of patients, falls, and/or accidents while providing assistance with grooming and transfers to these already compromised (weakened or impaired health condition) patients. (Refer to G754) 2. The HHA failed to ensure that a supervisory visit for the home health aide was conducted by a Registered nurse (RN) every 14 days for two of 7 sampled patients (Patient 2 and Patient 4). This deficient practice resulted in the lack of staff oversight and supervisory assessment of the aide services being provided to the patients. (Refer to G808) The cumulative effect of these systemic practices resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation for Organization and Administration of Services as follows: 1. The HHA failed to ensure a Certified Home Health Aide (CHHA) furnishing HHA services for two of seven sampled patients (Patient 1 and Patient 2) had a current CHHA license to practice in the agency. The deficient practice had the potential to result in all certified patients for home health services will be provided substandard care jeopardizing their health and safety, and wellbeing. (Refer to G952). The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to ensure all certified patients for home health services receive the highest quality of patient care.”

“Continuing need for home care CFR(s): 484.55(c)(3) The patient’s continuing need for home care; This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the patient’s continuing need for home care services for two of 7 sampled patients (Patients 4 and 5). This deficient practice resulted in the continued certification of the patients to receive the skilled nursing (SN) services. Findings: During a review of Patient 4’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 7/04/2024, with a diagnosis of Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and other abnormalities of gait and mobility. During a review of Patient 4’s Home Health Certification and Plan of Care (POC) for the certification period from 11/1/2024 to 12/30/2024, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a joint home visit, on 1/22/2025 at 11:55 a.m., conducted at Patient 4’s residence with the licensed vocational nurse (LVN 1), Patient 4 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory using a walker, accompanied by a family member (FM 1) and a caregiver. During an interview, FM 1 stated Patient 4 goes to visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and he helped managed Patient 4’s medication and diet regimen. During a concurrent interview and record review, on 1/23/2025 at 12:50 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting November 2024 to January 2025, Patient 4’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 4 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 4 should have been discharged because her goals have been met and there was no need for skilled nursing services. During a review of the agency’s undated policy and procedure (P&P) titled, Patient Discharge Process, the P&P indicated discharge planning is initiated for every home care patient at the time of the patient’s admission for home care. Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. Criteria for discharge may include but are not limited to the following: the patient has reached defined goals and is no longer in need of home care. 2. During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 7/03/2024, with a diagnoses which included Type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and long term use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 12/30/2024 to 2/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient twice daily for 60 days for insulin injection and management, assessment of patient with type 2 diabetes, and compliance with medication regimen. During a joint home visit, on 1/22/2025 at 10:50 a.m., at Patient 5’s residence with the registered nurse (RN 1), Patient 5 was observed sitting in a sofa, awake, alert, and oriented x 3 (to person, place, and time). During a review of Patient 5’s current medication, on 1/22/2025 at 11:10 a.m., with RN 1, a bottle of Humalog insulin (a fast-acting insulin that helps control blood sugar levels) and Crestor 20 milligram (mg, a unit of measurement) 1 tablet daily (treat high cholesterol level) were not found. However, Patient 5’s current medication profile list provided by the HHA indicated Patient 5 was still taking these medications. During a concurrent interview with Patient 5, stated she was not taking Humalog insulin and Crestor 20 mg for several months per physician’s order. During an interview, on 1/23/2025 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated nursing staff need to review the patient’s current medication on every nurse visit and update the medication profile in the patient’s clinical record right away. There was no documented evidence the HH staff confirmed with the physician the patient no longer takes the insulin medications for several months and the need for continued provision of SN services twice daily.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to maintain an accurate, current medication profile for one of seven sampled patients (Patient 5). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. Findings: During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 7/03/2024, with a diagnoses which included Type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and long term use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 12/30/2024 to 2/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient twice daily for 60 days for insulin injection and management, assessment of patient with type 2 diabetes, and compliance with medication regimen. During a joint home visit, on 1/22/2025 at 10:50 a.m., at Patient 5’s residence with the registered nurse (RN 1), Patient 5 was observed sitting in a sofa, awake, alert, and oriented x 3 (to person, place, and time). During a review of Patient 5’s current medication, on 1/22/2025 at 11:10 a.m., with RN 1, a bottle of Humalog insulin (a fast-acting insulin that helps control blood sugar levels) and Crestor 20 milligram (mg, a unit of measurement) 1 tablet daily (treat high cholesterol level) were not found. However, Patient 5’s current medication profile list provided by the HHA indicated Patient 5 was still taking these medications. During a concurrent interview with Patient 5, she stated she was not taking Humalog insulin and Crestor 20 mg for several months per physician’s order. During an interview, on 1/23/2025 at 12:50 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated nursing staff need to review the patient’s current medication on every nurse visit and update the medication profile in the patient’s clinical record right away. During a review of the agency’s undated policy and procedure (P&P) titled, Medication Profile, the P&P indicated the registered nurse, or therapist will complete a medication profile for each client at the time of admission. The medication profile shall include all prescription and nonprescription including regularly scheduled medications and those taken intermittently or as needed. The profile will be reviewed and updated as needed to reflect current medications the client is taking.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure and provide documented evidence the Certified Home Health Aides (CHHA) successfully completed the competency testing and training, to carry out assigned patient care tasks, in a safe, effective, and efficient manner for five of 7 sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, and Patient 6). This deficient practice placed the patients at risk for bodily injuries related to mishandling of patients, falls, and/or accidents while providing assistance with grooming and transfers to these already compromised (weakened or impaired health condition) patients. c. During a review of Patient 4’s Face Sheet, the Face Sheet indicated a SOC date of 7/04/2024, with a diagnosis which included Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and other abnormalities of gait and mobility. During a review of Patient 4’s Home Health Certification and POC for the certification period from 11/1/2024 to 12/30/2024 and from 12/31/2024 to 2/28/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks, and for the CHHA to visit once a week for 9 weeks to assist patient with ADLs, personal care and hygiene. During a record review of CHHA 3‘s Care Staff Actual Visits, it indicated CHHA 3 was assigned and visited Patient 4 at least once a week from 11/2/2024 to 1/16/2025. During a review of CHHA 3’s Employee Personnel Record on 1/23/2025, it indicated CHHA 3’s date of hire at the HHA was on 3/9/2023. However, there was no documentation regarding staff competency checklist found in CHHA 3’s personnel file. d. During a review of Patient 5’s Face Sheet, the Face Sheet indicated a SOC date of 7/03/2024, with a diagnosis which included Type 2 diabetes, and long-term use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). During a review of Patient 5’s Home Health Certification and POC for the certification period from 10/31/2024 to 12/29/2024 and from 12/30/2024 to 2/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient twice daily for 60 days for insulin injection and management, assessment of patient with type 2 diabetes, and compliance with medication regimen, and for CHHA to visit once a week for 9 weeks to assist patient with ADLs, personal care and hygiene. During a record review of CHHA 4‘s Care Staff Actual Visits, it indicated CHHA 4 was assigned and visited Patient 5 at least once a week from 11/1/2024 to 1/15/2025. During a review of CHHA 4’s Employee Personnel Record on 1/23/2025, it indicated CHHA 4’s date of hire at the HHA was on 1/8/2023. However, there was no documentation regarding staff competency checklist found in CHHA 4’s personnel file. e. During a review of Patient 6’s Face Sheet, the Face Sheet indicated a SOC date of 7/03/2024, with a diagnosis which included other folate deficiency anemias (The lack of folic acid in the blood. Folic acid is a B vitamin that helps your body make red blood cells), and Parkinson’s disease. During a review of Patient 6’s Home Health Certification and POC for the certification period from 10/31/2024 to 12/29/2024 and from 12/30/2024 to 2/27/2025, the POC included an order for the SN to visit the patient once a week for 9 weeks, and for CHHA to visit once a week for 9 weeks to assist patient with ADLs, personal care and hygiene. During a record review of CHHA 5‘s Care Staff Actual Visits, it indicated CHHA 5 was assigned and visited Patient 6 at least once a week from 11/4/2024 to 1/15/2025. During a review of CHHA 5’s Employee Personnel Record on 1/23/2025, it indicated CHHA 5’s date of hire at the HHA was on 11/24/2023. However, there was no documentation regarding staff competency checklist found in CHHA 5’s personnel file. During an interview with the Director of Patient Care Services (DPCS), on 1/23/2025, at 1 p.m., the DPCS stated CHHA 1, CHHA 2, CHHA 3, CHHA 4, and CHHA 5 staff was not provided a staff orientation and competency assessment upon their hiring to the agency. The DPCS stated the HHA staff had missed providing safety training on assistance and transferring to CHHA 1, CHHA 2, CHHA 3, CHHA 4, and CHHA 5. During a review of the agency’s undated policy and procedure (P&P) titled, Employee Orientation, the P&P indicated all employee and contracted staff who has patient and family contact would receive an orientation that includes training specific to job requirements. During a review of the agency’s undated policy and procedure titled, Staff Competency Program, the P&P indicated the patient care staff will be completely assessed at defined intervals; for each new employee during orientation and at least every three years. The hospice aide’s competency will be assessed and observed by an RN (registered nurse). The competency evaluation checklist will be completed and retained in the employee’s record. a. During a record review of Patient 1’s Patient Demographics, the Patients Demographics indicated a start of care on 6/5/2024, with a primary diagnosis of Vitamin B deficiency. During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period from 10/3/2024 to 12/1/2024, Patient 1’s Home Health Certification and Plan of Care indicated an order for the Certified Home Health Aide (CHHA) frequency of visits of once a week for nine weeks, to provide CHHA services for assisting with transfer and ambulation and personal hygiene and grooming. During a record review of CHHA 1‘s Care Staff Actual Visits, indicated CHHA 1 was assigned and visited Patient 1 from dates 10/4, 10/11, 10/18, 10/25, and 10/31/25, 11/1, 11/8, 11/15, 11/22, and 11/29/24. During a review of CHHA 1’s Employee Personnel Record indicated CHHA 1’s license certificate was issued on 7/18/2024, and the date of hire at the HHA was on 4/22/2025. However, there was no documentation regarding staff orientation or competency checklist found in CHHA 1’s personnel file. b. During a record review of Patient 2’s Patient Demographics, the Patients Demographics indicated a start of care on 6/2/2023, with a primary diagnosis of Diabetes Mellitus with diabetic nephropathy. During a review of Patient 2’s Home Health Certification and Plan of Care for the certification period from 11/23/2024 to 1/21/2025, Patient 2’s Home Health Certification and Plan of Care indicated an order for the Certified Home Health Aide (CHHA) frequency of visits of once a week for nine weeks, to provide CHHA services for assisting with transfer and ambulation and personal hygiene and grooming. During a record review of CHHA 3‘s Care Staff Actual Visits, indicated CHHA 3 was assigned and visited Patient 2 from dates 11/25/24, 12/2, 12/9, 12/16, 12/23, 12/30/24, 1/6, 1/13, and 1/20/25. During a review of CHHA 3’s Employee Personnel Record indicated CHHA 2’s license certificate was issued on 3/14/2019, and the date of hire at the HHA was on 9/23/2024. However, there was no documentation regarding staff orientation or competency checklist found in CHHA 1’s personnel file. During an interview with the Administrator (Adm)/Director of Patient Care Services (DPCS) on 1/23/2025, at 1 p.m., p.m., the Adm/DPCS stated CHHA 1, CHHA 2, CHHA 3, CHHA 4, CHHA 5 and CHHA 6 staff was not provided a staff orientation and competency assessment upon their hiring to the agency. The DPCS stated the HHA staff had missed providing safety training on assistance and transferring to CHHA 1, CHHA 2, CHHA 3, CHHA 4, CHHA 5 and CHHA 6. During a review of the agency’s undated policy and procedure titled, “Employee Orientation,” indicated all employee and contracted staff who has patient and family contact would receive an orientation that includes training specific to job requirements. During a review of the agency’s undated policy and procedure titled, “Staff Competency Program”, indicated the patient care staff will be completely assessed at defined intervals; for each new employee during orientation and at least every three years. The hospice aide’s competency will be assessed and observed by an RN (registered nurse). The competency evaluation checklist will be completed and retained in the employee’s record.”

“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 interview and record review, the Home Health Agency (HHA) failed to ensure that a supervisory visit for home health aide was conducted by a Registered nurse (RN) every 14 days for two of seven sampled patients (Patient 2 and Patient 4). This deficient practice resulted in the lack of staff oversight and supervisory assessment of the aide services being provided to the patients. Findings: During a review of Patient 4’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 7/04/2024, with a diagnoses which included Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and other abnormalities of gait and mobility. During a review of Patient 4’s Home Health Certification and Plan of Care (POC) for the certification period from 12/31/2024 to 2/28/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks, and home health aide to visit once a week to assist patient with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), personal care and hygiene. During a review of Patient 4’s clinical record indicated that there was no home health aide supervisory visit conducted on the dates between 12/27/2024 to 1/15/2025. During an interview, on 1/23/2025 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated home health aide supervisory visits should be conducted every two weeks by a registered nurse. The DPCS stated that for Patient 4, a registered nurse conducted a home health aide supervisory visit for Patient 4 on 12/13/2024 but none after that. The DPCS stated it was important for the RN to do a supervisory visit to make sure care and services were being provided to the patient in accordance with the home health aide care plan. During a review of the agency’s undated policy and procedure (P&P) titled, Certified Home Health Aide Supervision, the P&P indicated the purpose is to ensure patient personal care and services are provided in accordance with best practices, meet the patient’s needs, and promote positive patient outcomes. The Registered Nurse and/or Licensed Therapist, as appropriate, shall be responsible for making onsite visits to patient’s homes in order to complete Home Health Aide supervision within appropriate timeframes, as follows: at least every 14 days for patients receiving Home Health Aide services and skilled services (i.e. nursing, physical/occupational therapy, or speech-language pathology). a. During a record review of Patient 2’s Face Sheet, the Face Sheet indicated a start of care on 6/2/2023, with a primary diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Patient 2’s Home Health Certification and POC for the certification period from 11/23/2024 to 1/21/2025, Patient 2’s Home Health Certification and POC indicated an order for the CHHA frequency of visits of once a week for nine weeks, to provide CHHA services for assisting with transfer and ambulation and personal hygiene and grooming. During a review of Patient 2’s clinical record indicated that there was no home health aide supervisory visit conducted on the dates between 11/23//2024 to 1/04/2025. During an interview, on 1/23/2025 at 11 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated home health aide supervisory visits should be conducted every two weeks by a registered nurse.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure a Certified Home Health Aide (CHHA) furnishing HHA services for two of seven sampled patients (Patient 1 and Patient 2) had a current CHHA license/certificate to provide CHHA services at the agency. The deficient practice had the potential to result in all certified patients for home health services will be provided substandard care jeopardizing their health and safety, and wellbeing. b. During a review of CHHA 2’s Employee Personnel Record indicated a date of hire on 9/23/2024. A review of CHHA 2’s Board of Certified Home Health Aide license details, indicated CHHA 2 was issued a CHHA license on 3/14/2019 and the expired date of 8/28/2023. During a record review of Patient 2’s Patient Demographics, the Patients Demographics indicated a start of care on 8/2/2023, with a primary diagnosis of Diabetes Mellitus with diabetic nephropathy. During a record review of CHHA 2‘s Care Staff Actual Visits, indicated CHHA 3 was assigned and visited Patient 2 from dates 11/25/24, 12/2, 12/9, 12/16, 12/23, 12/30/24, 1/6, 1/13, and 1/20/25. a. During a review of CHHA 1’s Employee Personnel Record indicated a date of hire on 4/22/2024. A review of CHHA 1’s Board of Certified Home Health Aide license details, indicated CHHA 1 was issued a CHHA license on 7/18/2024 and the expired date of 9/29/2024. During a record review of Patient 1’s Patient Demographics, the Patients Demographics indicated a start of care on 6/5/2024, with a primary diagnosis of Vitamin B deficiency. During a record review of CHHA 1‘s Care Staff Actual Visits, indicated CHHA 1 was assigned and visited Patient 1 from dates 10/4, 10/11, 10/18, 10/25, and 10/31/25, 11/1, 11/8, 11/15, 11/22, and 11/29/24. b. During a review of CHHA 3’s Employee Personnel Record indicated a date of hire on 9/23/2024. A review of CHHA 3’s Board of Certified Home Health Aide license details, indicated CHHA 3 was issued a CHHA license on 3/14/2019 and the expired date of 8/28/2023. During a record review of Patient 2’s Patient Demographics, the Patients Demographics indicated a start of care on 8/2/2023, with a primary diagnosis of Diabetes Mellitus with diabetic nephropathy. During a record review of CHHA 3‘s Care Staff Actual Visits, indicated CHHA 3 was assigned and visited Patient 2 from dates 11/25/24, 12/2, 12/9, 12/16, 12/23, 12/30/24, 1/6, 1/13, and 1/20/25. During an interview on 1/23/2025, at 11:30 am., with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated if the CHHA’s license was expired, the agency would not allow the CHHA to see patients until the license gets renewed. A review of the HHA’s policy “Qualifications and Competency”, indicated every individual selected for employment shall have verified current licensure as required by applicable laws, regulations and standards.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) staff failed to submit nursing clinical notes within the timeframe as indicated in the agency’s policy and procedure for one of seven sampled patients (Patient 5). This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. Findings: During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 7/03/2024, with a diagnoses which included Type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and long term use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 12/30/2024 to 2/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient twice daily for 60 days for insulin injection and management, and for the home health aide to visit once a week for 9 weeks. On 1/23/2025, during a review of Patient 5’s Home Health Aide Visit Calendar, it indicated the last submitted home health aide visit note was dated 12/6/2024. During a phone interview, on 1/23/2025 at 11:45 a.m., with the certified home health aide (CHHA 4), CHHA 4 stated she visited Patient 5 at least once a week since last year for personal care and ADLs (activities of daily living - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). CHHA 4 stated she was supposed to submit her visit notes within 5-7 days after each visit but has not been able to because of her workload. During an interview, on 1/23/2025 at 12:50 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated visit notes from the home health aide for Patient 5 was late. The DPCS stated the agency policy for submission of nurse’s visit notes was to submit within 24 to 48 hours after the service was rendered. During a review of the agency’s undated policy and procedure (P&P) titled, Clinical Documentation, the P&P indicated agency will document each direct contact with the client. This documentation will be completed by the direct caregivers and monitored by the skilled professional responsible for managing the client’s care. Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record within seven (7) days after the care has been provided.”